CNO Advisory Committee Meeting Meeting Book PDF Free Download
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CNO Advisory Committee Meeting
Meeting Book
Wednesday, July 25, 2018
California Hospital Association - Boardroom
1215 K Street, Ste 800
Sacramento, CA, 95814
Conference Call Option:
800-882-3610 passcode: 7795222#
A. Roster
10:00 am I. CALL TO ORDER/INTRODUCTIONS
Kiger
10:05 am II. MINUTES
Kiger
1. NANDA Letter and Submission
10:15 am A. Nursing Diagnoses
BJ Bartleson
10:30 am B. Clinical Training Capacity
Judee Berg/Joseph Morris
10:45 am
1. SB 1288
11:00 am D. Legislation - SB 1288 and Parkinsons Registry Update
Debby Rogers
11:15 am
2. EHR Presentations from April 25, 2018 Meeting
1. Nursing Summit Dates and Locations
C. Nursing Community
Kim Tomasi / Marketa Houskova
2. Staffing Compliance Survey Results
III. OLD BUSINESS
Kiger
12:00 pm
1. Span of Control Presentation
1:00 pm B. Nursing Span of Control
Theresa Murphy / Terri Hollingsworth
A. CNO Survey and Questionnaire
V. NEW BUSINESS
Kiger
B. Committee Guidelines
A. Meeting Minutes - April 25, 2018
E. Legislation - SB 1152
Peggy Wheeler
11:30 am IV. LUNCH
Meeting Book - CNO Advisory Committee Meeting
CNO Advisory Committee Meeting - July 25, 2018
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Page 2 of 284
A. AONE Call for Abstracts
B. ACNL Nurse Leadership Information
C. Glendale Community College Nursing Program Helps Fill Critical Care
Gap
VI. INFORMATION
VII. NEXT MEETING
2. Nursing Span of Control Information
D. No Place Like Home: Advancing the Safety of Care in the Home
A. Wednesday, October 3, 2018
VIII. ADJOURNMENT
Kiger
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7/18/2018
CNO ADVISORY COMMITTEE
2018 ROSTER
Officers
Chair
Linda Burnes-Bolton, DrPH, RN, FAAN
Health System Chief Nurse Executive/Chief Nursing
Officer, Cedars-Sinai Medical Center
Cedars-Sinai Medical Center
8700 Beverly Boulevard
Los Angeles, CA 90048-1865
(310) 423-5191
linda.burnes-bolton@cshs.org
Chair
Anna Kiger, DNP, DSc, MBA, RN, NEA-BC
System Chief Nurse Officer
Sutter Health
2200 River Plaza Drive
Sacramento, CA 95833-4134
(916) 286-6843
kigeraj@sutterhealth.org
Members
Margarita Baggett, MSN, RN
Chief Clinical Officer
UC San Diego Health - Hillcrest Medical Center
9300 Campus Point Drive
San Diego, CA 92037
(858) 249-5537
mbaggett@ucsd.edu
Gloria Bancarz, MSN, RN
Vice President/Chief Nursing Officer
Adventist Health
2100 Douglas Boulevard
Roseville, CA 95661-3898
(916) 781-4690
gloria.bancarz@ah.org
Theresa Brodrick, RN, PhD
Regional Chief Nursing Officer
Kaiser Permanente Northern California Region
1950 Franklin Street
Oakland, CA 94612-3610
(510) 987-4502
Theresa.m.brodrick@kp.org
Jennifer R. Castaldo, MSHA, BSN, RN, NEA-BC
Vice President/Chief Nursing Officer
Henry Mayo Newhall Hospital
23845 McBean Parkway
Valencia, CA 91355-2083
(661) 200-1027
castaldojr@henrymayo.com
Timothy L. Clark, BSN, MBA, RN
Regional Chief Nursing Officer Division I
Prime Healthcare Services
3300 Guasti Road
Ontario, CA 91761
(909) 687-3590
ticlark@primehealthcare.com
Jerome Dayao, MSN, RN, NEA-BC, CPHQ, HACP,
CCRN, PCCN
Chief Nursing Officer
Arrowhead Regional Medical Center
400 North Pepper Avenue
Colton, CA 92324-1819
(909) 580-6180
dayaoj@armc.sbcounty.gov
Annette Greenwood, BSN, MHA, RNC
Senior Vice President/Chief Nursing Officer
Riverside Community Hospital
4445 Magnolia Avenue
Riverside, CA 92501-4199
(951) 788-3430
annette.greenwood@hcahealthcare.com
Karen Grimley, PhD, MBA, RN, FACHE, NEA-BC
Chief Nurse Executive, Assistant Dean UCLA School of
Nursing
Ronald Reagan UCLA Medical Center
757 Westwood Plaza
Los Angeles, CA 90095-8358
(310) 267-9304
kgrimley@mednet.ucla.edu
Page 4 of 284
CNO Advisory Committee Roster
7/18/2018
Beverly Hayden-Pugh, CNO
Senior Vice President, Clinical Integration, Patient
Experience/Chief Nursing Officer
Valley Children's Healthcare
9300 Valley Childrens Place
Madera, CA 93636-8761
(559) 353-6609
bhayden-pugh@valleychildrens.org
Linda Knodel, MHA, MSN, NE-BC, CPHQ, FACHE,
FAAN
Chief Nurse Executive/Senior Vice President,
National Patient Care Services
Kaiser Permanente Oakland Medical Center
One Kaiser Plaza
Oakland, CA 94612
(510) 409-9529
linda.j.knodel@kp.org
Michelle Lopes, MSN, RN, NEA-BC
Senior Vice President, Patient Care Services
John Muir Medical Center - Walnut Creek Campus
1601 Ygnacio Valley Road
Walnut Creek, CA 94598-3122
(925) 947-5343
michelle.lopes@johnmuirhealth.com
Toby Marsh, RN, MSA, MSN, FACHE, NEA-BC
Chief Nursing/Patient Care Services Officer
UC Davis Medical Center
2315 Stockton Boulevard
Sacramento, CA 95817-2282
(916) 734-2470
tkmarsh@ucdavis.edu
Terry Pena, MS-HCA, BSN, RN
Chief Operating Officer/Chief Nursing Officer
San Bernardino Mountains Community Hospital
29101 Hospital Road
Lake Arrowhead, CA 92352
(909) 436-3070
terry.pena@mchcares.com
Connie Rowe, RN, MHA, FACHE, CPHQ
CNO/Vice President, Patient Care Services
Enloe Medical Center - Esplanade Campus
1531 Esplanade
Chico, CA 95926-3386
(530) 332-7369
connie.rowe@enloe.org
Katie Skelton, RN, MBA, NEA-BC
VP Patient Care Services/Chief Nursing Officer
St. Joseph Hospital, Orange
1100 West Stewart Drive
Orange, CA 92868-3891
(714) 771-8270
katie.skelton@stjoe.org
Lauren Spilsbury, RN, MSN
CNO/Vice President, Patient Care Services
Redlands Community Hospital
350 Terracina Boulevard
Redlands, CA 92373-4897
(909) 335-5513
las@redlandshospital.org
Sylvain Trepanier, DNP, RN, CENP, FAAN
Chief Clinical Executive
Providence St. Joseph Health Southern California
20555 Earl Street
Torrance, CA 90503-3006
(310) 793-8076
Sylvain.trepanier@providence.org
Pam Wells, MSN, MSA, RN, NEA-BC
Chief Nursing Officer and Vice President, Patient Care
Services
Sharp Memorial Hospital
7901 Frost Street
San Diego, CA 92123-2701
(858) 939-3523
pam.wells@sharp.com
Page West, RN, MPA, MHA, HACP
Senior Vice President/Chief Nursing Executive
Dignity Health
185 Berry Street
San Francisco, CA 94107-1773
(415) 438-5668
page.west@dignityhealth.org
Page 5 of 284
CNO Advisory Committee Roster
7/18/2018
Advisory/Ex-Officio
Judee Berg, MS, RN, FACHE
Chief Executive Officer
HealthImpact
663 13th Street
Oakland, CA 94612
(510) 832-8400
judee@healthimpact.org
Mary Bittner, DNP, MPA, RN, CENP
Adjunct Faculty, School of Nursing and Health
Professions (SONHP)
San Francisco State University
2130 Fulton St.
San Francisco, CA 94117
bittnermary2@gmail.com
Pilar De La Cruz-Reyes, MSN, RN
Vice President
Health Education Alliance
3866 N. Academy Ave.
Sanger, CA 93657
ralip151@hughes.net
Anita Girard, DNP, RN, CNL, CPHQ, NEA-BC
Vice President
American Nurses Association/California
1121 L Street
Sacramento, CA 95814
(408) 396-0162
vicepresident@anacalifornia.org
Marketa Houskova, MAIA, BA, RN
Executive Director
American Nurses Association/California
1121 L Street, Suite 406
Sacramento, CA 95814
(916) 346-4590
marketa@anacalifornia.org
Dennis Kneeppel, RN, MPA, CPHQ, NEA-BC, FACHE
Chief Operating Officer/Chief Nursing Executive
Association of California Nurse Leaders
1200 El Camino Real
South San Francisco, CA 94080-3208
(650) 742-2401
Dennis.kneeppel@kp.org
Joseph Morris, PhD, MSN, RN
Executive Officer
California Board of Registered Nursing
1747 N. Market Boulevard
Sacramento, CA 95834-1924
(916) 574-7603
joseph.morris@dca.ca.gov
Kimberly Tomasi, MSN, RN
Chief Executive Officer
Association of California Nurse Leaders
2520 Venture Oaks Way
Sacramento, CA 95833
(916) 779-6949
kim@acnl.org
Debbie Ward, RN, PhD, FAAN
Interim Dean
Betty Irene Moore School of Nursing, UC Davis
2570 48th Street
Sacramento, CA 95817
(916) 734-2215
dhward@ucdavis.edu
Heather Young, PhD, RN, FAAN
Associate Vice Chancellor for Nursing
Betty Irene Moore School of Nursing, UC Davis
2570 48th Street
Sacramento, CA 95817
(916) 734-4745
hmyoung@ucdavis.edu
Page 6 of 284
CNO Advisory Committee Roster
7/18/2018
Staff
BJ Bartleson, MS, RN, NEA-BC
Vice President Nursing & Clinical Services
California Hospital Association
1215 K St.
Sacramento, CA 95814
(916) 552-7537
bjbartleson@calhospital.org
Debby Rogers, RN, MS, FAEN
Vice President Clinical Performance &
Transformation
California Hospital Association
1215 K St.
Sacramento, CA 95814
(916) 552-7575
drogers@calhospital.org
Jenna Fischer, CPPS
Vice President, Quality Improvement and Patient
Safety
Hospital Council of Northern and Central California
3480 Buskirk Avenue
Pleasant Hill, CA 94523
(925) 746-5106
jfischer@hospitalcouncil.org
Teri Hollingsworth
Vice President, Human Resource Services
Hospital Association of Southern California
515 South Figueroa Street
Los Angeles, CA 90071-3300
(213) 538-0763
thollingsworth@hasc.org
Judith R. Yates, BSN, MPH
Senior Vice President
Hospital Association of San Diego and Imperial
Counties
5575 Ruffin Road
San Diego, CA 92123
(858) 614-1557
jyates@hasdic.org
Barbara Roth
Administrative Assistant
California Hospital Association
1215 K Street, Suite 800
Sacramento, CA 95814
(916) 552-7616
broth@calhospital.org
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GUIDELINESFORTHE
CALIFORNIAHOSPITALASSOCIATION
CNOADVISORYCOMMITTEE
I. NAME
ThenameofthiscommitteeshallbetheCNOAdvisoryCommittee
II. MISSION
ThemissionoftheCNOAdvisoryCommitteeistoadviseCHAonkeypolicyandadvocacyissues
specifictohospitalandhealthsystemnurseexecutivepractice.
III. PURPOSE
ThepurposeoftheCNOAdvisoryCommitteeistoprovidesupportformemberhospitalsandto
solicitinputforCHAadvocacyonkeyissues.
Thecommitteewillprovideaforumto:
1. Provideadviceandexpertanalysisonissuesofimportance.
2. CooperatewithCHAonprogramsandactivitiesandtosupportthepositionsandservicesof
CHA.
3. Makerecommendationsrelatedtostateandfederallegislationandregulationsrelatedto
hospitalandhealthsystemnursingandclinicalservices.
4. ConductotheractivitiesapprovedbytheCHABoardofTrustees.
IV. COMMITTEE
TheCommittee(the“Committee”)shallconsistofnomorethan25votingmembers
representativeofthetypes,location,andsizeofCHAinstitutionalmembers.
A. MEMBERSHIP
1. MembershipontheCommitteeshallbebaseduponinstitutionalmembershipinCHA.
2. Committeemembersshallconsistofvariousrepresentativesfromlargehospital
systems,publicinstitutions,privatefacilities,free‐standingfacilities,smallandrural
facilities,university/teachingfacilitiesandspecialtyfacilities.
3. Non‐hospitalmemberswillbeconsideredex‐officiomembersincludingfaculty,
consumersandothermembersofthehealthprofessionswhoarebeneficiariesof
nursingpracticeandcanonlybeappointedtothecommitteeatthediscretionofthe
CHAstaff.
4. CommitteemembersareappointedbyCHAstaff.
5. Committeemembersshallservethree‐yeartermsstaggeredinafairandequitable
mannerasdeterminedbythenominatingcommitteeandacceptedbytheCommittee.
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CHA CNO Advisory Committee Guidelines
June 20, 2017
Revised
Page 2
12/19/2017
Membersarelimitedtotwoconsecutiveterms.Theremustbeatleastaone‐year
intervalbeforebeingeligibleforanotherterm.
B. MEMBERRESPONSIBILITIES
1. Accepttheirappointmentwithaninterestandwillingnesstoserve.
2. Marktheircalendarswiththeadvancenoticeofmeetingsfortheyearandmakeevery
reasonableefforttokeepthosedatesandtimesopenforthemeeting.
3. Attendeverymeetingpossible.
4. Bepreparedbyreviewinganydiscussionmaterialprovidedinadvanceofthemeeting.
5. Contributetothediscussionandconsiderthesubjectmatterforthebenefitofthe
associationasawhole,notjustanindividualmember.
6. Respondtorequestsforinputandfeedbackonbusinessandissuesbeforethe
Committee.
7. Disseminateinformationtocommitteesandtomemberorganizationsasappropriate.
C. COMMITTEEMEETINGS
1. MeetingsoftheCommitteeshallbeheldquarterlyinperson.Additionalconferencecall
orweb‐basedmeetingsmaybescheduledasindicated.
2. Tomaintaincontinuitysubstitutionofmembersisnotnormallyallowed.
3. ThreeconsecutiveunexcusedabsencesbyaCommitteememberwillinitiateareviewby
theChairandCHAstafffordeterminationoftheCommitteemember’scontinued
serviceontheCommittee.
4. SpecialmeetingsmaybescheduledbytheChair,majorityvoteorCHAstaff.
D. VOTING
1. VotingrightsshallbelimitedtomembersoftheCommittee,andeachmemberpresent
shallhaveonevote.Votingbyproxyisnotacceptable.
2. AllmattersrequiringavoteoftheCommitteemustbepassedbyamajorityofaquorum
oftheCommitteememberspresentatadulycalledmeetingortelephoneconference
call.
E. QUORUM
Exceptassetforthherein,aquorumshallconsistofamajorityofmembers
present/participatingornotlessthaneight.
F. MINUTES
MinutesoftheCommitteeshallberecordedateachmeeting,disseminatedtothe
membership,andapprovedasdisseminatedorascorrectedatthenextmeetingofthe
Committee.
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CHA CNO Advisory Committee Guidelines
June 20, 2017
Revised
Page 3
12/19/2017
V. OFFICERS
TheofficersoftheCommitteeshallbetheCommitteeChair,ViceChair,ImmediatePastChair
andCHAstaff.
TheChairshallbeappointedbyCHAstaffforatwo‐yearterm.ShouldaChairvacatehis/her
positionpriortotheendoftheterm,CHAstaffwillappointareplacementtocompletethe
remainderoftheterm.
TheresponsibilitiesoftheCommitteeChairareto:
1. MonitorstaffintheexecutionoftheirresponsibilitiestotheCommittee.
2. Conductmeetingswhichassureanorderlyflowofthediscussionandaconstructiveuseof
thegroup’stime.
3. InterprettheactionoftheCommitteeandspeakfortheCommitteewhennecessaryto
reporttotheCHABoardofTrustees.
TheresponsibilitiesoftheCommitteeViceChairareto:
1. AssisttheChairintheexecutionofhis/herresponsibilitiestotheCommittee.
2. IntheabsenceoftheChair,assumetheroleandresponsibilitiesoftheChair.
VI. GENERALPROVISIONS
A. COMMITTEEACTIVITIES
Committeeactivities,includinggoalsandobjectives,shallbedevelopedbytheCommittee
withapprovalbyCHAstaff.Quarterlyupdatesandprogressreportsshallbecompletedby
theCommitteeandCHAstaff.Committeestaffshouldcommunicateregularlywiththe
CommitteeontheactivitiesandprioritiesoftheCommittee.TheCommitteemayrequest
thatstaffdevelopageneralworkplanwhichdefinesthegoalsandobjectivesofthe
Committeeforthecomingyear.
B. SUB‐COMMITTEES
TaskforcesorsubcommitteesoftheCommitteemaybeformedatthediscretionofthe
CommitteeChairandmemberandCHAstaffforthepurposeofconductingactivitiesspecific
toaspecialtopicorgoal.
C. STAFFSUPPORT
StaffleadershipshallbeprovidedbyCHAwithRegionalAssociationstaffleadership
providedbyHospitalCouncil,theHospitalAssociationofSouthernCalifornia,andthe
HospitalAssociationofSanDiegoandImperialCounties.Theprimaryofficeandpublic
policydevelopmentandadvocacystaffoftheCommitteeshallbelocatedwithintheCHA
office.
Page 10 of 284
CHA CNO Advisory Committee Guidelines
June 20, 2017
Revised
Page 4
12/19/2017
VII. AMENDMENTS
TheseGuidelinesmaybeamendedbyamajorityvoteofthemembersoftheCommitteeatany
regularmeetingoftheCommitteeandwithapprovalbyCHA.
VIII. LEGALLIMITATIONS
AnyportionoftheseGuidelineswhichmaybeinconflictwithanystateorfederalstatutesor
regulationsshallbedeclarednullandvoidasofthedateofsuchdetermination.
AnyportionoftheseGuidelineswhichareinconflictwiththeBylawsandpoliciesofCHAshall
beconsiderednullandvoidasofthedateofthedetermination.
Informationprovidedinmeetingsisnottobesoldormisused.
IX. CONFIDENTIALITYFORMEMBERS
Manyitemsdiscussedareconfidentialinnature,andconfidentialitymustbemaintained.All
Committeecommunicationsareconsideredprivilegedandconfidential,exceptasnoted.
X. CONFLICTOFINTEREST
AnymemberoftheCommitteewhoshalladdresstheCommitteeinotherthanavolunteer
relationshipexcludingCHAstaffandwhoshallengagewiththeCommitteeinabusinessactivity
ofanynature,asaresultofwhichsuchpartyshallprofiteitherdirectlyorindirectly,shallfully
discloseanysuchfinancialbenefitexpectedtoCHAstaffforapprovalpriortocontractingwith
theCommitteeandshallfurtherrefrain,ifamemberoftheCommittee,fromanyvoteinwhich
suchissueisinvolved.
Page 11 of 284
7/19/2018
CNO ADVISORY C
OMMITTEE
MEETING MINUTES
April 25, 2018 / 10:00 a.m. – 2:00 p.m.
Sutter Health
2200 River Plaza Drive, Sacramento, CA
Members Present: Judee Berg, Mary Bittner, Linda Burnes-Bolton, Theresa Brodrick, Jennifer
Castaldo, Jerome Dayao, Pilar De La Cruz-Reyes, Beverly Hayden-Pugh, Teri
Hollingsworth, Marketa Houskova, Anna Kiger, Dennis Kneeppel, Toby Marsh,
Joseph Morris, Terry Peña, Connie Rowe, Katie Skelton, Pam Wells, Heather
Young
Members on Call: Margarita Baggett, Tim Clark, Jenna Fischer, Susan Herman, Lauren Spilsbury
Members Absent: Gloria Bancarz, Mary Bittner, Anita Girard, Annette Greenwood, Karen Grimley,
Linda, Knodel, Michelle Lopes, Kim Tomasi, Sylvain Trepanier, Page West
Guests: Julie Martin, Emily Barey, Amye Guilio, Cathy Turner
Staff: BJ Bartleson, Debby Rogers, William Emmerson, Gail Blanchard-Saiger, Jenna
Fischer, Teri Hollingsworth, Judith Yates, Barb Roth, Sarah Cardone
I. CALL TO ORDER/INTRODUCTIONS
The committee meeting was called to order by Chair Linda Burnes-Bolton at 10:00 a.m.
Request for members to review the committee guidelines.
CHPAC –Emmerson
Mr. Emmerson introduced committee members to the Nurse Ambassador level of donation
and the importance of CHPAC participation.
II. REVIEW OF PREVIOUS MEETING MINUTES
The minutes of the January 17, 2018, CHO Advisory Committee conference call were
reviewed.
IT WAS MOVED, SECONDED AND CARRIED:
ACTION: minutes approved.
III. OLD BUSINESS
A. Nursing Diagnosis (Bartleson, Berg)
HealthImpact conducted a study about how California RNs describe their work, through
nursing diagnoses. The study compared what RNs learn in school and how they use nursing
diagnoses in practice. Results show nurses describe their work as tasks rather than through the
nursing process that identifies a nursing diagnosis. More information is needed to identify
how Electronic Health Records (EHR) reflect the professional work of nursing. Instructors are
teaching the functionality of the EHR without consideration about the validation of the nursing
process.
The survey indicates the vast majority of schools teach nursing diagnoses in varying degrees;
Page 12 of 284
7/19/2018
either a specific class dedicated to the topic or it is weaved throughout the curriculum.
However, the NCLEX exam does not include nursing diagnosis.
It is important for nursing diagnosis to be person (patient)-focused. The person is a part of the
team and has some level of some ownership. Every person of the team contributes. If
instructions get too discipline specific, it will leave others out of the diagnosis and care
discussion, including the person.
Individual presentations by EHR representatives:
1. Epic (Emily Barey)
PDF attachment provided
2. Cerner ( Amye Gilio)
PowerPoint presentation
3. Meditech (Cathy Turner)
PowerPoint presentation
LOINC – the universal standard for identifying health measurements, observations, and
documents.
ACTION: Ms. Bartleson will be presenting the study findings at the NANDA International
Conference and will report back to the group
B. BRN Update (Dr. Morris)
Effective April 5, 2018, licensing fees have increased. The RN renewal fee will be $150 every 2
years and a new license fee has been increased to $300. This increase was passed by law. A
portion of the fees will be used to provide improved customer service.
Action – Information Only
C. Nursing Diagnosis Abstract Presentation NANDA International (Bartleson)
ACTION: Ms. Bartleson will update the members at the next meeting.
IV. LEGISLATION
A. Proposed Rule on Protecting Conscience Rights in Health Care (Keefe)
The rule will be finalized later this year and CHA believes the Administration will not change
any part of it. There are many questions and much ambiguity. Some of the questions may not
be able to be answered until tested. These rules were initially reviewed by the CHA Human
Resources (HR) Committee. It looks like the rules are expanding beyond traditional procedures
to anything that might conflict with an employee’s conscious or moral objections. For instance
as it moves away from procedures (healthcare professional not wanting to participate in a
procedure) to patients (not wanting to treat a specific patient). Most hospitals have policies
but HR is not hearing about problems at this time. Their thought is that objections are being
handled on the floor by managers on an as needed basis.
There is concern about balancing moral/conscious objection of care for a specific patient vs. a
procedure vs. discrimination against the patient. CNOs report that these incidents are
happening every day and the managers on duty are responding with reasonable
accommodations.
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7/19/2018
ACTION: Ms. Keefe will keep the committee updated on the policies or procedures that
may need to be reviewed.
B. Key State Issues (Bartleson)
FYI
ACTION: Information only.
V. NEW BUSINESS
A. CalOSHA Workplace Violence Reporting Mandate (Blanchard-Saiger)
The implementation date for the regulation was April 1, 2018. Everyone should have been
trained with assessments and undertaken corrective actions. CalOSHA posts the list of
hospitals and number of incidents without providing information about the nature of the
incidents. It is not a searchable database at this time.
ACTION: Ms. Blanchard-Saiger offered to work with a subcommittee on this topic.
ACTION: Through ANA, Ms. Houskova and Ms. Blake are part a task force on nursing
workplace violence. Ms. Banchard-Saiger and Ms. Houskova will be in communication
to discuss this further.
B. Clinical Displacement (Bartleson/Tomasi)
The Quad Council has submitted a letter to BRN regarding Clinical Displacement. Dr. Morris
affirms that the BRN is committed to addressing this matter with the support of community
partners, not only from academia but from industry. All board meetings are recorded and the
issue comes up at every meeting. Legislators are also beginning to look at this.
The first pilot for dual ADN/BSN enrollment (Cal State system) is scheduled to roll out in 2019,
allowing the completion of a Bachelors within 6 months or less. More information is scheduled
to be revealed in the Fall 2018. BRN strongly encourages all schools to be involved in this
process.
Dr. Morris initially envisioned a statewide summit on clinical training placement issues High
level academic and practice executives need to be involved in the process. The planning group
has suggested regional summits versus one statewide summit. CHA, Health Impact, and the
Quad Council, along with state community college workforce staff are collaborating on this
initiative.
ACTION: More Information will be provided at the next meeting
C. CNO Survey and Questionnaire (Bartleson)
ACTION: Tabled until the next meeting
D. Nursing Community (Bartleson/Tomasi/Houskova)
ACTION: Tabled until the next meeting
VI. ROUNDTABLE DISCUSSION
ACTION: Tabled until next meeting
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7/19/2018
VII. NEXT MEETING
Wednesday, July 25, 2018
VIII. ADJOURNMENT
Having no further business, the committee adjourned at 2:00 PM
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July 25, 2018
TO: CNO Advisory Committee Members
FROM: BJ Bartleson, MS, RN, NEA-BC, Vice President, Nursing and Clinical Services
Judee Berg, MS, RN, FACHE, CEO HealthImpact
SUBJECT: Nursing Diagnosis Presentation at NANDA- International Conference
SUMMARY
CHA presented, “Use of Nursing Diagnosis in California Nursing Schools and Hospitals” at the June 13th,
2018, North American Nursing Association International Annual Conference at Boston College Connell
School of Nursing, the new home of NANDA. (See Attachments) The NANDA work has recently left
University of Iowa and relocated to Boston College, while NIC and NOC remain at University of Iowa.
The meeting was well attended by over 200 people from multiple countries, USA, Japan, Peru, Mexico,
Brazil, Netherlands, Spain, Argentina, Canada and many more. Many countries teach and practice
NANDA exclusively, while others commented on similar issues we are experiencing with lack of
standardization and consistency across facilities and academia. EMR vendors were also present to
discuss their views
In our previous CNO meeting, CHA hosted Epic, Cerner and Meditech Vendors, who each shared their
means of displaying the nursing process and how it is translated within their systems. (See attachments)
There is no consistency between the EMR systems. Cerner’s focus is on nursing diagnosis within the
interdisciplinary plans of care, with mention of nursing diagnosis as it aligns with other disciplines. For
example “self-care deficit IPOC”, aligns with team care and overall health care outcomes. So, while this
supports a holistic plan of care for the management of patients across the continuum, it was difficult to
understand the distinct contribution of nursings work. Meditech, clearly identified the use of Zynx,
NANDA, CCC and other diagnostic language and how they link evidence, performance and key measures.
Their representative, Cathy Turner, was also at the NANDA-International conference. Epic seemed to
have the most clear decision support system and intermingle the term nursing diagnosis/problem
interchangeably.
Clearly, there are many barriers to adoption and or use of nursing diagnosis as a means to describe
nursings work.
DISCUSSION
How do we differentiate nursing practice in California and move forward with Future of Nursing,
Institute of Medicine goals, such as full practice authority and a highly educated workforce?
How do we collectively define our practice in a clear and concise way, that can be measured,
discussed and used to advance health care in public policy and advocacy?
Are there other ways to be clear about our scope, and dimensions of practice to enhance
necessary innovation and regulatory change for future practice?
Page 16 of 284
Nursing Diagnoses Presentation at NANDA International Conference
July 25, 2018
Page 2
ACTION REQUESTED
Committee discussion on next steps
Attachments: NANDA Conference Participant Letter
NANDA Submission
Cerner Presentation
EPIC Presentation
Meditech Presentation
BJB:br
Page 17 of 284
Boston College Connell School of Nursing
July 8th, 2018
Dear Conference Participants, Presenters and Guests:
Thank you for helping to make the first NANDA-I Conference at Boson College (BC) such an amazing
success. Although there were glitches from time to time, staff were very responsive to challenges and
the incoming conference evaluations provided by conference participants BC have been very positive.
The Pre Conferences meetings set the stage for participant interest in and excitement for nursing
diagnosis. Presentations buy the NANDA-I Board Members and Keynote presentations helped to create
an environment for transition and change. The Boston College Campus provided an environment of
scholarly inquiry and reflection. Having conference events in this historic location, offered participants
multiple opportunities to explore the future of NANDA- I and knowledge development. Social events
celebrated member achievements, recognized excellence, explore NANDA-I archival information and
promoted fellowship within an international community of nurse scholars.
We hope each of you continue be involved in NANDA-I and continue to access new updates and new
information about the NANDA-I BC partnership on the NANDA-I and Boston College websites. In
addition, if you have not participated in the conference evaluation please complete the brief evaluation
questionnaire sent to you after the conference by email.
In addition, I have also have many inquiries from members and conference participants about
supporting the Marjory Gordon Program for Knowledge Development and Clinical Reasoning and the
Gordon International Post-Doctoral Fellows Program. Those interested in providing a gift to the Gordon
Program can do so by making out a check to the Boston College Board of Trustees and indicate on the
lower left side of the check that the gift is for the Marjory Gordon Program - Gordon International Post-
Doctoral Fellows. Checks can be sent to Christopher Grillo, Associate Dean OF Finance and
Administration, Boston College, Connell School of Nursing, Maloney Hall/ 21 Campanella Way- Chestnut
Hill, MA 02467. We appreciate your support.
We look forward to working with you in the coming years and seeing you in June of 2020 at the next
NANDA-I /BC Conference. For additional information, contact Rozanna Riley, at 617 552–3547.
Sincerely,
Dorothy Jones EdD, ANP, FAAN, FNI
Director, Marjory Gordon Program for Nursing Knowledge Development and Clinical Reasoning
Page 18 of 284
NursingDiagnosis&KnowledgeDevelopment:NewBeginnings
PaperPresentationAbstractSubmission
SubmittedtoNANDAInternational,Inc.forJune13‐15,2018,Conference
Authors: CarolynOrlowski,MSN,RN,southernregionaldirector,HealthImpact,carolyn@healthimpact.orgJudeeBerg,
MS,RN,FACHE,CEO,HealthImpact,judee@healthimpact.org
BJBartleson,RN,MS,NEA‐BC,vicepresident,nursingandclinicalservices,CaliforniaHospitalAssociation,
bjbartleson@calhospital.org
IntroductionwithProblemStatement
In2017,Californianurseleadersexecutedastatewideefforttodefinenursing’svalue.
1
Researchersexploredways
todemonstratethenursingprofession’sunique—thoughlargelyinvisible—contributions.UndertheCalifornia
NursePracticeAct
2
,registerednursesarerequiredtoformulateanursingdiagnosis.Thisstudyanalyzedregistered
nurses’rolesindiagnosticprocesses,includingsubsequentdevelopmentofeffectiveplansandtargeted
interventionstoachieveclinicaloutcomes.
Methods
Usingsurveys,thestudyexploredhowregisterednursingstudentsinpre‐licensureprogramsaretaughtthenursing
diagnosisprocessandhownursesutilizenursingdiagnosisinpractice.Whileeachsurveyinstrumentcontained
uniquequestions,sixcommonquestionsexploredareasofsimilarityorvariationinperspectiveandpractices.Each
surveyincludedmultiplechoicequestions,open‐endedquestionsandspaceforcomments.
ResultsandDiscussion
Thirtyschoolsand34hospitalsresponded.93.3percentofregisterednursingpre‐licensureprogramsindicatedthat
nursingdiagnosiswasaformalcurriculumcomponent,butmanyreportedthattheydonotobserveregistered
nursesusingitinpractice.Ofthehospitalssurveyed,only24percentreportedusingNANDA‐Imethodology;36
percentofhospitalsindicatedthat,whiletheyexpectnursestoutilizenursingdiagnosis,theyhadnotadopteda
specificmethodorapproach.
ImpactontheDiscipline
Widevariabilityexistsbetweenhowschoolsteachandhowhospitalsusenursingdiagnosis—despiteagreement
thatitisakeyfactorindescribingnursing’svalue.Academicandprofessionalleadershaveanopportunitytoimprove
theconsistentuseofnursingdiagnosestohighlightnursing’svalue.
1
HealthImpactWhitePaper,UseofNursingDiagnosisinCaliforniaNursingSchoolsandHospitals,ReportofStatewideSurveyResults,Copyright2018,
https://healthimpact.org/wp‐content/uploads/2018/02/Use‐of‐Nursing‐Diagnosis‐in‐CA‐Nursing‐Schools‐and‐Hospitals_JAN‐2018.pdf
2
Business&ProfessionsCode,Chapter6,NursingSection2725,theStandardsofCompetentPerformance(CaliforniaCodeofRegulations,Title
16,Section1443.5)andtheCaliforniaCodeofRegulations(Title22,Section70215)
ABSTRACT
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Nursing Diagnosis & Knowledge Development: New Beginnings
Authors: CarolynOrlowski,MSN,RN,southernregionaldirector,HealthImpact,carolyn@healthimpact.orgJudeeBerg,
MS,RN,FACHE,CEO,HealthImpact,judee@healthimpact.org
BJBartleson,RN,MS,NEA‐BC,vicepresident,nursingandclinicalservices,CaliforniaHospitalAssociation,
bjbartleson@calhospital.org
Thespecificresponsibilityregisterednurses(RN)haveinassessingpatientresponsetohealthandillnessand
determiningevidence‐basedetiologyiswithintherealmofnursing’sautonomousscopeofpractice,andis
referredtoasnursingdiagnosis.Itisanessentialelementofthenursingprocessandisfollowedby
implementingspecificinterventionswithinnursing’sscopeofpractice,providingevidencethatlinks
professionalpracticetohealthoutcomes.Thedeliberateuseofnursingdiagnosisasanelementinthenursing
processelevatestheinvisiblenatureofnursing’smostimportantworkinassessingandaddressingpeople’s
responsetohealthandillness.Theveryuseofnursingdiagnosislanguageincareplanningand
communicationmakesvisiblethefundamentalimportance/contributionsofnursesregardlessofpractice
settingorcaredeliverymodel,andutilizationofitisakeycomponentthatevidencestheuniquecontribution
andvalueofnursing.
TheCaliforniaNursingPracticeAct(Business&ProfessionsCode,Chapter6,NursingSection2725),the
StandardsofCompetentPerformance(CaliforniaCodeofRegulations,Title16,Section1443.5),andthe
CaliforniaCodeofRegulations(Title22,Section70215),allspeaktotheresponsibilityofRNstoformulatea
nursingdiagnosisforpatientsundertheircare.Yetthereiswidevariabilitybetweenhowschoolsteachitand
howhospitalsuseitinpractice.Providingevidenceofnursing’sroleindiagnosticprocesseswithsubsequent
developmentofeffectiveplansandtargetedinterventionstoachieveclinicaloutcomeswasexploredinthis
studyasoneapproachtodemonstratingnursing’slargelyinvisible,uniquecontributionandvalue.
HealthImpactconductedadescriptivestatewidesurveyofCaliforniahospitalsandnursingpre‐licensure
programstounderstandhowstudentsaretaughtandlearnaboutthenursingdiagnosticprocess,andhow
nursesworkinginhospitalsutilizenursingdiagnosisinpractice,includingwrittenandverbalcommunication.
Toinformthedesignofthequestionnaire,areviewoftheliteraturewasconductedtoexploretheprevalence,
application,barriersandeffectivenessofthenursingdiagnosticprocess,andtheuseofnursingdiagnosis
terminologyandvariousmethodsofdocumentingandcommunicatingit.
INTRODUCTION
STUDY METHODOLOGY
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Twosurveyquestionnairesweredesigned,oneintendedforpre‐licensurenursingprograms(“schoolsurvey”)
exploringhowRNstudentsweretaughtandlearnedaboutnursingdiagnosis,andaseparatequestionnaire
designedforhospitals(“hospitalsurvey”)focusedonhowRNsinpracticeperformedthenursingdiagnostic
process.Whileeachsurveyinstrumentcontaineduniquequestions,asetofsixcorequestionscommonto
bothsurveysexploredwheretheremaybesimilarityorvariationinperspectivesandpractices.Eachsurvey
includedacombinationofmultiplechoicequestions,open‐endedquestions,andoptionsforcommentstobe
submitted.
Theschoolsurveywasdisseminatedtodeans,directors,and/orchairsof143CaliforniaRNpre‐licensure
programs(91ADN,38BSN,14MastersEntryProgramsinNursingPrograms,MEPN).Academicleaderswere
requestedtoidentifyonenursingfacultyexpertwhowasmostknowledgeableabouthownursingdiagnoses
aretaughttonursingstudentsintheirpre‐licensureprogramstocompletethequestionnaireonbehalfofthe
school.Thirty(30)responseswerereceivedfora21.1%responserate.
Thehospitalsurveywasdisseminatedtochiefnursingofficersrepresenting433hospitals.Nursingexecutives
wererequestedtoidentifyonenurseexpertwhowasmostknowledgeableabouteducation,monitoring,
and/orevaluatinghownursesutilizenursingdiagnosesintheirorganization,tocompletethequestionnaireon
behalfofthehospital.Thirty‐four(34)responseswerereceived,fora7.9%responserate.
∙Pre‐LicensureSchoolPrograms∙
Overthree‐fourthsoftheacademicrespondentscompletingthesurveyrepresentedADNschoolsofnursing.
Amajorityofschoolsreportedprovidinginstructioninnursingdiagnoses,with28(93.3%)RNpre‐licensure
programsindicatingitwasaformalpartoftheircurriculumandonly2(6.7%)indicatingitwasnotformally
taught.ThetwoschoolsthatreportednotteachingnursingdiagnosiswereacommunitycollegeADNprogram
andaprivateLVNtoADNprogram.
TheNANDA(NorthAmericanNursingDiagnosisAssociation)Internationaldefinitionsandclassificationisthe
mostcommonmethodbeingtaught,asreportedby21(70%)ofprograms.Sixnursingprograms(20%)
reportedusingNANDAlistsasareference,withlessformalityappliedintheexpectationsofstudentswhen
forming,writingandcommunicatingdiagnosticstatements,andoneprogram(3.3%)indicatedtheydonot
specifyorutilizeastandardapproach.Twoprograms(6.7%)indicatedusingvariationsofNANDAaswellas
incorporatingconceptmappingthroughoutthecurriculum.
Nursingschoolswereaskedwhennursingdiagnosisisfirstformallytaughtintheirprograms.Whileall
programsreportteachingnursingdiagnosis,itistypicallytaughtinaspecificcourseduringthefirstsemester
ofthenursingprogram.Commentsindicatestudentsareexpectedtoapplynursingdiagnosesthroughoutall
semestersoftheprogram,andcontentcantypicallybefoundintegratedindidacticcoursesandcasestudies
aswellasinclinicalsettingswhencaringforpatients.
SURVEY PARTICIPATION
KEY FINDINGS AND RESULTS
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Schoolswereaskedtosharethemostsignificantchallengesorbarrierstoteachingnursingdiagnosesand/or
forstudentstolearnanddevelopcompetenciesinthediagnosticprocesswithintheirscopeofnursing
practice.Responsessubmittedwerereviewedandsynthesized,withthemostfrequentlyreportedfindings
summarizedasfollows:
Terminology(“language”or“vocabulary”)ischallengingtolearn,notusedinpractice
WorkingwithRNsthatpredominantlyutilizethemedicalmodelmorethannursingdiagnosismodel
inhibitsapplicationoflearningandlimitsaddressingpatientresponsenotlinkedwithmedical
diagnoses
ClinicalfacilityrestrictionsonaccessingEMRinhibitapplicationoflearningprocess
Hospitalpracticespre‐setandutilizealimitednumberandtypeofnursingdiagnoses
Learningdifferencesbetweenanactualorpotentialproblem,identifyingdata(evidence)tosupportit
Limitationof(some)EMRsystemstoutilize,connect,andconveythis
Facultycompetencyandexperienceinclinicalpractice
Theintroductiontothesurveystatedthat“utilizationofnursingdiagnoses(specifically)isakeycomponent
thatevidencestheuniquecontributionandvalueofnursing.”Uponcompletingthequestionnaire,amajority
ofrespondents(70%)eitherfullyorsomewhatagreedwiththatstatement.
Thissamestatementandfinalquestionwereposedinboththehospitalandnursingschoolsurveys,andthe
distributionofresponsesbylevelofagreementordisagreementwasfoundtobecomparable.Comments
receivedfromschoolsprovidefurtherinsightintothisquestion,representedbytheseexamples:
“Thebodyofknowledgerelatedtonursingdiagnosesisnotlarge;thereismoreevidencerelatedto
implementationofnursingpracticeandactions.”
“Agreetheyareanimportantpartofpatientcare,yethospitalspredominantlyadoptthemedicalmodel
andcommonpatientproblemlanguage.”
“Nursingprocessandnursingdiagnosesreinforcetheindependentfunctionsoftheprofessionalnurse.
Basingnursingpracticesolelyonthemedicalmodellimitsscopeofpracticeandrangeofpatientneedsto
bemet.”
“Thebiggestbarriertonursingprovidinganddocumentingcarehasbeentheelectronichealthrecord,with
nursingassessmentandinterventionsconfinedtocheckboxesratherthandescriptivenotes.Valuable
informationisfoundinphysicianprogressnotes.”
∙HospitalsandHospitalSystems∙
Hospitalrespondentscompletingthesurveyincluded34acutecarehospitalsandhospitalsystemsacross
California,representingvarioussizesandtypesofacutecarehospitals.
Theterm“nursingdiagnosis”usedthroughoutthesurveyreferredtothespecificresponsibilityRNsmayhave
inassessingpatientresponsetohealth,determiningevidence‐basedcauses,andmakingdecisionsregarding
interventionstobeimplementedwithinthescopeofnursingpractice.Variousapproachesareidentifiedto
expressandcommunicatenursingdiagnoses,whileprofessionalpracticemethodsandhospitalexpectationsin
usingaspecificmethodalsodiffer.Hospitalsrespondingtothesurveymostfrequently(36%)indicatedthat
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whiletheyexpectnursestoutilizenursingdiagnosis,theorganizationhadnotidentifiedaspecificmethodor
approachtobeadopted.
Hospitalsprovidedinformationaboutapproachesusedforplanninganddocumentingpatientcarethat
typicallyinvolveelectronichealthrecords,andmayincludeaninterprofessionalteamapproachinadditionto
thenursingplanorinplaceofit.Thesmallsamplesizeandvariationofresponseslimitedquantitative
analysis;however,asampleofdescriptivefindingsissummarized.
Electronichealthrecordsprovideablendedapproachofmedicaldiagnosesandevidence‐based
humanresponsesalignedwithnursingdiagnosestosupportpotentialoractualhealthproblems
throughtemplatesprovided
Clinicalpracticeguidelineslinkedtotheelectronichealthrecord,withreferencetoNursing
InterventionsClassification(NIC)notedonsomeelectronichealthrecordtemplates
Patientproblemlistisusedinadditiontonursingdiagnoses
Patientproblemlistisusedinsteadofnursingdiagnoses
Utilize(standard)careplansbasedonmedicaldiagnoses,withareferencelistofcommonproblems
Patientplanofcaredoesnotusenursingdiagnoses,andisinterprofessional
Nursingprocessscreenwithintheelectronichealthrecordcontainsalistofpotentialassessment
findingsoutsidenormaldefinedparameters;nursingselectionreflectsidentifiedneeds
UtilizeNANDA’sNursingInterventionsClassification(NIC)andNursingOutcomesClassification(NOC)
inelectronichealthrecordworkflowmanagementsoftware;however,terminologyisnotfaceupor
evident
Softwareintegratesaninterprofessionalapproachtoapatientplanofcare
Electronichealthrecorduseslistsofnursingdiagnoseswithattachedpatientproblemlistsand
interventionsthatthenurseselectsfrom
Themajorityofhospitals(88.2%)reportedcapturingnursingdatasetsandinterventionselectronicallyfrom
electronicmedicalrecords,ratherthanrelyingonmanualdocumentationmethods,withasmallnumber
(8.8%)reportingnursingdatasetsareonlyavailablemanually.
ThelevelofresponsibilityRNshaveinidentificationofnursingdiagnosesaspartofthenursingprocessshowa
prevalenceofreferringtonursingdiagnosisreferencelistsorsources,andselectingorfollowingstandardpre‐
plannedinterventionsasthebasisforcareplanning,whilehavingtheoptiontoindividualizeandprioritize
interventionsasindicatedandastheconditionofthepatientandneedschange.
Todetermineaccuratenursingdiagnoses,nursesconsidermedicaldiagnoses,nursingassessmentfindings,
andrelevantetiologybasedonsourcesofpatientinformationandrelateddatatoaccuratelyinterpretpatient
responsestotheirhealthproblems.Overhalfofthehospitalsrespondingtothesurvey(58.8%)reportthey
havenotreviewed,evaluated,orvalidatedtheaccuracyofnursingdiagnosesandassociatedinterventions
usedwithpatients.Hospitalsthatdoreportdoingso(41.2%)indicatetheyvalidatetheaccuracythroughsuch
activitiesasRNshiftreport,reviewbychargeRNs,auditsandpeerreview.
HospitalswereaskedtosharethemostsignificantchallengesorbarriersforRNsindevelopingcompetencies
inthediagnosticprocesswithinthescopeofnursingpractice.Responsessubmittedinopentextboxformat
werereviewedandsynthesized,withthemostfrequentlyreportedfindingssummarized.
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Limitedtime,timemanagement,andcompetingprioritiespracticinginfast‐pacedcomplex
environments
Lackofcriticalthinkingskillsandexperience,limitedclinicaljudgement
Limitedadvancedpracticeandeducationresources,professionaldevelopmentatpointofcare
Limitedassessmentskillsanddifferentiatingetiologysufficienttoinformcorrectnursingdiagnoses
Oneapproachtomeasuringthequalityofnursingcarethatcontributestopatientoutcomesistolinknursing
diagnoseswithassociatedinterventionsandevaluatepatientoutcomesinthatcontext.Amajorityofhospital
respondents(61.8%)indicatedtheirorganizationsdonotutilizesuchaggregatedatadocumentedonnursing
diagnosesandnursinginterventionswithgroupsofpatientstoidentifynursing’scontributiontoandimpact
onpatientoutcomes.Ofthe6(17.7%)hospitalsthatindicatedtheyutilizeaggregatenursingdatatoevaluate
patientoutcomes,fiveofthesewerelargehospitalsandpartofmulti‐hospitalsystems.
Intheintroductiontothesurvey,itwasstatedthat“utilizationofnursingdiagnoses(specifically)isakey
componentthatevidencestheuniquecontributionandvalueofnursing.”Uponcompletingthequestionnaire,
amajorityofrespondents(78%)eitherfullyorsomewhatagreedwiththatstatement.
Thissamestatementandfinalquestionwereposedinboththehospitalandnursingschoolsurveys,andthe
distributionofresponsesbylevelofagreementordisagreementwasfoundtobecomparable.Comments
receivedfromhospitalsprovidefurtherinsightintothisquestion,representedbytheseexamples:
“Provingnursingimpactonhealthoutcomesremainsverydifficult,andincreasinglytheonlysubstantive
evidenceofnursingcontributionisbypublishingdatasetstolargenationaldatabases(NDNQI),and
examiningnursingsensitiveindicators.Ifnursingcollectivelyandconsistentlystatednursingsensitive
indicatordataintermsofnursingdiagnosticstatements,thesecouldthenbeconsideredmoresalientin
provingnursingimpact.”
“Nursingdiagnosisisanecessarycomponentofnursingscience.Itprovidesdirectionforinterventionsand
evaluationoftheireffectivenessinthecareofthepatient.”
“Theentirenursingprocess,especiallytheindependentfunctions,demonstratethevalueofnursing.”
Thisstatewidesurveyexaminedhownursingstudentsinpre‐licensureprogramsaretaughtandlearnabout
nursingdiagnoses,andhownursingdiagnosesareutilizedbynursespracticinginhospitalsinCalifornia.This
studywasconductedaspartoftheoverallworktodefinethevalueofnursing,byexploringhowthenursing
diagnosticprocessisusedanditsspecificcontribution.Findingsfromthesurveysmaynotberepresentative
ofnursingprogramsandhospitalsinCaliforniaoverallduetothelowresponserate.Itispossiblethatthose
respondingtothesurveyinvitationmayhaveaparticularinterestinnursingdiagnosis,whichcouldalso
influencethefindings.Withtheseconsiderationsinmind,thedataobtainedandcommentsreceivedprovide
insightsforconsideringhowusingnursingdiagnosiscansupportthevalueofnursingandmayeveninfluence
howRNsthemselvesconceiveoftheiroverallrole.
SchoolsofnursingprovidingRNpre‐licensureprogramsreportintroducingnursingdiagnosisearlyinthe
curriculum,typicallyaspartofanursingfundamentalscourse,andwithinthecontextoflearningtheoverall
CONCLUSIONS
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nursingprocess.Themajority(93.3%)ofrespondentsindicatedteachingnursingdiagnosisasaformalpartof
thecurriculumthatcontinuestobereinforcedinothercoursesandclinicaleducationexperiencesapplied
throughouttheacademicprogram.WhileapproachestoteachingstudentsaboutnursingdiagnosisinRNpre‐
licensureprogramsvary,theNANDAInternationaldefinitionsandclassificationisthemostcommonevidence‐
basedmethod,beingtaughtby70%ofnursingprogramsreporting.Learningistypicallysupportedthrough
reviewofcasestudies,assignmentsandactivities,andapplicationwhenprovidingdirectpatientcare.Nursing
programsindicatediagnosticcompetenciesareanessentialpartofthenursingprocessthatreliesonthe
integrationofemergingknowledgeandcriticalthinkingskillsdevelopedovertime.Schoolsreportthathow
theyteach(andstudentslearnandusenursingdiagnosis)isimportanttothedevelopmentofdiagnostic
competenciesneededtoaccuratelyidentifyevidence‐basedplansofcareandinterventionsaspartofthe
nursingprocess.Schoolsalsoreportexperiencingwidevariationacrossaffiliatedclinicalsiteswherestudents
arescheduledinhownursingdiagnosesmaybeutilizedinpractice,integratedinplansofcareandcapturedin
electronichealthrecords.
Hospitalsrespondingtothesurveymostfrequently(36%)indicatedthatwhiletheyexpectnursestoutilize
nursingdiagnosis,theirorganizationhasnotidentifiedaspecificmethodorapproachtobeadopted.The
widespreadimplementationofelectronichealthrecordsandtheircontinuedevolutionhaveinfluencedhow
patientdataiscaptured,howcareandservicesaredocumentedbyvarioushealthprofessionals,andhow
recordsareutilizedbytheinterprofessionalteamincoordinatingandcarryingoutplansofcare.Some
electronichealthrecordsprovideablendedapproachofmedicaldiagnosesandevidence‐basedhuman
responsesalignedwithnursingdiagnosestosupportpotentialoractualhealthproblemsthroughtemplates
providedasinterprofessionalplansofcare,thoughmostdonot.
Hospitalsreportnursingpracticetrendsemphasizingstandardizedplansandassociatedinterventionstobe
carriedoutlargelydrivenbymedicalorders,policy,andregulatoryandsafetyconcerns.Contributingfactors
mayincludelow‐levelcompetencyinnewlylicensedRNsrelatedtonursingdiagnoses,theexpectationsofthe
professionalpracticeenvironmentnursesworkwithin,theshortlengthsofstayinwhichonlyprioritiesofcare
canbeaddressed,andorganizationalprocessesandsystemsthatlimitorsupporttheeffectivedevelopment
andefficientintegrationofthenursingprocessincaredelivery.Whilemosthospitalsreportlackofvisible
formalnursingdiagnosisstatementsorlanguagebeingused,thereisevidencesomehaveformallyintegrated
NANDAorothersourcesandstandardsintotheelectronichealthrecordprogramming.Further,inthese
instancesassessmentfindingsguidethedevelopmentofproblemlists(whichmayincorporatenursing
diagnoses)andselectionofspecificinterventionsthatsupporttheautonomousnursingroleleadingtothe
determinationofindividualizedplansofcareandspecificinterventions.
Whilethesmallsurveysizediscouragesbroadconclusions,itseemsthereisclearlyanopportunitytobuildon
themajorityopinionsofsurveyrespondersfrombotheducationandpracticethatutilizationofnursing
diagnosis(specifically)isakeycomponentthatevidencestheuniquecontributionandvalueofnursing.With
nursingdiagnosiscurrentlymoreembeddedinnursingeducationinCaliforniathaninpracticesettings,itis
incumbentonpracticeleadersandpractitionerstodeterminehowbesttoclosethisgapandexposethe
unique,butinvisible,workofprofessionalRNs.
Whileamajorityofhospitals(88.2%)reportedcapturingnursingdatasetsandinterventionselectronically
fromelectronicmedicalrecords,only17.7%indicateusingsuchdatatoevaluatenursingoutcomes.Thereis
furtheropportunitytostrengthentheevidencelinkingnursingdiagnosticprocesseswiththeidentificationand
developmentofeffectiveplansandtargetedinterventionstoclinicaloutcomesdemonstratingnursing’s
uniquecontributionandvalue.
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References:
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Graduation.InternationalJournalofNursingTerminologiesandClassifications,21(3),124‐133.
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Frigstad,S.A.,Nost,T.H.,&Andre,B.(2015,May13).ImplementationofFreeTextFormatNursingDiagnosesata
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DiagnosticCompetencyandtheAnalysisofFactorsInfluencingCompetencyUsingWrittenCaseStudies.International
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Kurashima,S.,MSN,RN,Kobayashi,K.,MD,Toyabe,S.,MD,&Akazawa,K.,PhD.(July‐September,2008).Accuracyand
EfficiencyofComputer‐AidedNursingDiagnosis.InternationalJournalofNursingTerminologiesand
Classifications,19(3),95‐101.doi:10.1111/ijnt.2008.19.issue‐3
Lavin,M.A.,ScD,RN,BC,ANP,FAAN.(April‐June,2002).President'sAddress.NursingDiagnosis,13(2),62‐65.
Lavin,M.A.,ScD,RN,FAAN,Avant,K.,PhD,RN,FAAN,Craft‐Rosenberg,M.,PhD,RN,FAAN,Herdman,T.H.,PhD,RN,&
Gebbie,K.,DrPH,RN,FAAN.(April‐June2004).ContextsfortheStudyoftheEconomicInfluenceofNursingDiagnoses
onPatientOutcomes.InternationalJournalofNursingTerminologiesandClassifications,15(2),39‐47.
Lavin,M.A.,ScD,RN,CS,ANP,FAAN,Meyer,G.,MSN(R),RN,CS,&Carlson,J.H.,MSN,RN,CS,GNP.(April‐June,1999).
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Maas,M.,PhD,RN.(April‐June,2000).ResponsetoS.Beyea's"NursingDiagnosisorPatientProblem?"Nursing
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Müller‐Straub,M.,PhD(c),MNS,EdN,RN,Needham,I.,PhD,MNS,EdN,RN,Odenbreit,M.,MNS,EdN,RN,Lavin,M.A.,
ScD,RN,FAAN,&VanAchterberg,T.,PhD,MSc,RN.(January‐March,2007).ImprovedQualityofNursing
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Müller‐Straub,M.,PhD,MNS,EdN,RN.(January‐March,2009).EvaluationoftheImplementationofNursingDiagnoses,
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Paganin,A.,RN,Moraes,M.A.,RN,MSc,Pokarski,S.,RN,&Rabelo,E.R.,RN,ScD.(October‐December,2008).Factors
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Palese,A.,MSN,BCN,RN,DeSilvestre,D.,BCN,RN,Valoppi,G.,MSN,RN,&Tomietto,M.,MSN,BCn,Rn.(April‐June,
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Wier‐Hughes,D.,EdD,MA,BSc(Hons),RN,FRSH.(September,2007).ReviewingNursingDiagnoses.Nursing
Management,14(5),32.
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Regional Director and Healthcare Executive
Amye Gilio MSN, RN-BC
Translation of Nursing Diagnosis
Care Planning - Care Delivery - Value
Plans of Care in Review:
Episodic plans
Nursing value
Cost of Care
Cross Continuum plans and the future of value
Consumer Engagement
Linear Record and Holistic Plans of Care
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Cerner’s Patient Focused Plan of Care
Interdisciplinary
Plans based on
Assessment
Interdisciplinary
Plans based on
Assessment
Medical Order
sets based on
diagnosis
Medical Order
sets based on
diagnosis
Patient’s
Plan of
care
Patient’s
Plan of
care
Quality
Quality
Quality
Quality
Interdisciplinary Plan of Care Workflow
Patient
Assessed
Patient
Condition/
Risk Identified
IPOC Initiated
and Monitored
IPOC
Interventions/
Care Delivered
IPOC
Outcomes
Updated
Clinicians alerted if
the patient is at risk
and the IPOC is
suggested
Patient data is
monitored for
risk factors
IPOC guides Interventions and tracks expected
patient care Outcomes
As patient care is
delivered and
documented IPOC
Outcomes are updated
Ongoing patient
assessments
A DYNAMIC,
CONTINUOUS
process which
allows the clinician
to modify care as needed
Page 29 of 284
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3
Interdisciplinary Plans of Care - Value
•Proactive approach to the patient’s care delivery process
•Ensure value occurs at the bedside by pushing content based on
practice standards at the point of care
•Facilitate compliance with with regulatory requirements
•Leverage technology to support the coordination of care
•Leverage technology to transform clinical practice and remove
memory based practices
•Facilitate interdisciplinary review of the entire plan of care by
creating awareness of all disciplines contributions
•Nursing manages overall plan of care and care coordination
IPOC Content Strategy Tied to Value- DRG Alignment
Page 30 of 284
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4
15 Nursing Standards IPOCs
Anxiety IPOC
At Risk for Aspiration IPOC
At High Risk for Bleeding IPOC
Bowel Dysfunction IPOC
Decreased Cardiac Output IPOC
Fluid Volume Deficit IPOC
Impaired Communication IPOC
Impaired Skin Integrity IPOC
Ineffective Airway Clearance IPOC
Ineffective Coping IPOC
Knowledge Deficit IPOC
Nutritional Deficit IPOC
At Risk for Infection IPOC
At Risk for Unstable Glucose IPOC
Self Care Deficit IPOC
Details can be found at the following link (navigate to the Acute Nursing Content
Guide spreadsheet, IPOCs tab)
https://wiki.ucern.com/display/public/ModelExperience/Acute+Care+Venue
•Start with an industry accepted resource for content
recommendations
•Use the same terminology/phrasing as the evidenced
based problems
1. Doenges, Marilynn E,Moorhouse, Mary FrancesandMurr, AliceC. Nursing Diagnosis Manual,
Planning, Individualizing andDocumenting ClientCare.3
rd
ed.,Philadelphia, PA, F.A.Davis
Company,2010.
2. Doenges, Marilynn E,Moorhouse, Mary FrancesandMurr, AliceC.Nursing CarePlans,
Guidelines forIndividualizing ClientCareAcross theLifeSpan.9
th
ed.,Philadelphia, PA, F.A.
DavisCompany,2014.
3. Gulanick, Meg andMyers, Judith L.Nursing CarePlans, Diagnoses, Interventions, and
Outcomes.8
th
ed.,Philadelphia, PA,Elsevier Mosby, 2015.
Creating Custom Plans of Care
Page 31 of 284
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5
Capture health and care plan data
Health
concerns
Activities &
Interventions
Goals
Care Team
Outcomes
Page 32 of 284
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6
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7
Current State Challenge
Lack of a patient-centric plan of care that supports
patient engagement, care team coordination and
evolving market, industry, regulatory and client needs
BRNDEXP 2.0 0714 © 2014 Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information belonging to Cerner Corporation and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of Cerner.
12
A connected, person-centric health & care experience
The Longitudinal Care Plan
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8
patient-
centric
across all
care
settings
longitudinal
and
episodic
supports
and
involves
entire care
team
eliminate
plan
workflow
silos
seamless
regulatory
support
personal
care team
engaged
One
Plan
a plan of care model that
supports the patient and care
team in management of the
holistic plan across the
continuum and patient
lifespan, to facilitate personalized
health management and care
delivery to optimal outcomes
Page 35 of 284
with the patient at the heart
w
w
w
w
w
i
th
h
e
a
a
r
r
t
t
t
t
Assessment to Diagnosis
•Assessment tools
•Most common remains flowsheets
or form based assessments
•Content configurable to match the
clinical practice standard and
policy of the organization
•Additional patient data elements
may be part of decision support to
suggest a diagnosis, plan or
intervention
•Age, gender, history, social
determinant of health, medications,
lab results, etc.
* Note – flowsheet row names and list choices may also be coded in the Epic
database, most commonly as LOINC & SNOMED codes
Page 36 of 284
Decision Support for Problem Diagnosis
Clinical Decision Support may be configured to reflect the clinical practice standard of the organization
including which terminology should be used.
* You may open the Problem Template from here to choose specific Goals
and Interventions
Step 1 to Individualize the Problem Diagnosis template
•The Epic Foundation System is very
loosely based on NNN
•We have customers live on
•NNN
•CCC
•But many have also purchased third
party content
•Elsevier’s CPM is most common
•It is currently mapped to SNOMED &
LOINC terms
•There is a license fee for NNN
•CCC is free with letter of agreement
* The nurse may select or deselect specific goals or interventions before
applying them to the patient’s care plan.
Page 37 of 284
Step 2 to Individualize the Problem Diagnosis template
* The nurse may choose to add details or edit items in the Problem,
Goal, or Intervention to individualize the plan.
* Clicking the Problem opens the form for editing.
The Plan & Interventions
The plan consists of the Interventions and the frequency assigned.
These Interventions can display as part of the nurse’s assessment
flowsheet to make it easier to incorporate into shift documentation.
The Plan is also available as a patient summary report to support the
handoff and / or team based rounds workflows.
Page 38 of 284
Actionable Handoff & Team Based Rounds Review
Evaluation
NOC Goals can be incorporated and the scale may be modified to support 1-5 (vs. met, not met)
Page 39 of 284
Evaluation to Progress Note
Correlating data and diagnosis, goal progression
Page 40 of 284
Daily Care Plan Reporting
Nurse Scorecard
Page 41 of 284
Barriers to adoption: Nursing Diagnosis
•Lack of knowledge at all levels to develop and implement nursing
terminologies
•Including mapping the use of the diagnosis to specific processes such as handoff and
team based rounds
•Perception that they are not interdisciplinary
•Display names vs. mapping the codes in the database could help here
•Epic can support multiple terminologies – ok if other disciplines want their own
•Perception that NIC interventions are not evidenced based
•And how to incorporate evidence into interventions (this is where templates can be
helpful or combo of Pathway + Care Plan for human response)
•Broadly lacking “teeth” at national level as a profession or from payers within
hospital setting
Page 42 of 284
Questions?
•Emily Barey, MSN
•(608) 271-9000
•ebarey@epic.com
Page 43 of 284
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1
TheNursingProcessinMEDITECH
CathyTurner,BSN,MBA,RN‐BC,
AssociateVicePresident,MEDITECH
@MEDITECH_Nurses
Faculty,NortheasternUniversity,Boston,MA
Faculty,UniversityofMiami,Florida
Nursing’suniquecontributionandvalue
1) How does Meditech describe nursing
practice/outcomes within its system?
2) Does Meditech use NANDA International
terminology
3) Can activities be collated /assigned to specific
staff and or patients?
Page 44 of 284
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2
KeyComponents
• Supports the Nursing Process
• Comprehensive and Flexible
- Supports multiple methodologies
* Actual and potential risks
- Nursing diagnosis vs problems
* Zynx evidence based care plans *
* NANDA
* CCC
* Other nursing theories/models
• Multi-disciplinary
- Global vs discipline/skill specific views
• Dynamic with documentation
• Value add
NursingProcess
• Observe and Document
• Assess
• Diagnose
• Planning
• Implementing
• Evaluate
• Assessment triggers
suggested nursing diagnoses,
outcomes and interventions
• Care plan created as
byproduct of above
• Monitor and Document
progress
• Evaluate results and modify
Page 45 of 284
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3
Structureiseasy
But must operationalizing this to make it meaningful,
interactive and d
y
namic
Structure is easy
Structure
●Plan of care
-Nursing Diagnosis or Problem
-Outcome
-Intervention
- Assessments
-Queries
* One query theory
* Based on clinical decision support, Assessments trigger:
^Diagnoses/problems
^Interventions
^ Orders
●Standard content
-Provides ability for pre-built algorithms
-Actionable data
●135+ Care Plans
●600+ Assessments
- 3600 Queries
Page 46 of 284
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4
Dependencies,ActionableDataandValueAdd
• Standardization
- Consider ANA recommended terminology
mapped to LOINC or SNOMED
• Actionable Data
- Value Adds as by-product of documentation
-Quality metrics
-Scoring tools and algorithms
-Acuity
-Charging
PlanofCare‐ SpreadsheetMode
Page 47 of 284
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5
PlanofCare– Heirarchydisplay
EvidenceLinks,Performance&KeyMeasures
Page 48 of 284
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6
EvidenceLinks
PCSWorklist‐ attachedassessments
‐ globalvsspecificlist
Page 49 of 284
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7
PCSWorklist ‐ documentationforms
ActionableData
Documentation:
• Triggers suggested problems, interventions, orders
• Performs algorithms for messaging and alerts
• Populates Surveillance watchlists and status boards
• Calculates acuity
• Charges for procedure, time and supplies
Page 50 of 284
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8
CathyTurner,BSN,MBA,RN‐BC,
AssociateVicePresident,MEDITECH
@MEDITECH_Nurses
PredictEarly,ActFastwithSurveillance
● Evidence‐basedrulestargetat‐riskpopulations,aswellas
populationsthatqualifyforclinicalqualitymeasures
●ActionableSurveillanceBoards helpnursestoorderand
documentcareonthespot
● Watchlistsgivequalitymanagersahigh‐level
viewofpatientswhohavequalifiedfor
specificsurveillanceprofiles
●Notificationsinreal‐time accelerate
responsetime
○ Atthebedside
○ Tomobiledevices
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9
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10
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11
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12
Real‐WorldResults
MEDITECH's
Surveillance
ProvidesPower
OverInfections
atValley
MEDITECH’s6.1Surveillancepower
andversatilityismakingareal
differenceatTheValleyHospital
(Ridgewood,NJ).
With23surveillanceboardsinuse,
Valleyisyieldingimpressiveresults.
100%ofHIM‐codedsepticpatientswere
foundbyelectronicsurveillanceinMarch
2016.
93%ofpatientswhoqualifiedforsepsis
surveillanceboardwerecodedwithsepsis
diagnosisbyHIM(6/1/2015to5/15/2016).
Improvementin sepsis3‐hour
bundlecompliance.
78%to98%increasedcomplianceinflu
vaccineadministrationrates.
30minutesinestimatednursingtime saved
byeliminatingmanualcountsofurinary
cathetersandcentrallinesforCAUTIand
CLABSIrates.
93%VTEprophylaxiscompliancerate,a
dramaticimprovementfromthelow70s.
Page 55 of 284
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13
SepsisScreeningSavesLivesandMoney
Aspartofasystem‐widesepsis
preventioneffort,AveraHealth (Sioux
Falls,SD)integratedsepsisscreening
assessments,evidence‐basedorder
sets,andclinicaldecisionsupport
directlyintotheirMEDITECHEHR
nurseandphysicianworkflows.
45%reductioninsepsis
mortality
$10millioncostsavings based
ona$5,080costpercase
SepsisReadmissionRate
droppedfrom12.9%to10.3%
Readmissionobservedto
expectedratiofellfrom.70to
justabove.60‐ exceedingtop
performersinthenation
Page 56 of 284
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14
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15
CathyTurner,BSN,MBA,RN‐BC,
AssociateVicePresident,MEDITECH
@MEDITECH_Nurses
Page 58 of 284
July 25, 2018
TO: CNO Advisory Committee Members
FROM: Judee Berg, MS, RN, FACHE, CEO, HealthImpact
Joseph Morris, PhD, MSN, RN, Executive Officer, California Board of Registered Nursing
SUBJECT: Clinical Training Capacity
SUMMARY
As a follow-up to our last committee meeting, the Quad Council (ANA-C, ACNL, COADN, CACN), CHA, and
the BRN, have partnered to implement regional nursing summits to collectively discuss the clinical
training capacity issues with the broader nursing community, industry partners, and legislative staff, as
an alternative to legislative solutions. The purpose of the regional summits is to bring the varied interest
groups together to solve clinical placement issues for future changes in health care delivery. Bridging
gaps between academia and industry partners to implement a sound statewide program that honors the
regional diversity of schools and industry is the goal. Dr. Joanne Spetz will attend to deliver objective
data on the issues and all parties will be asked to contribute to solution innovation. Attached is a list of
the regional meeting dates. Labor will be invited to the meeting.
DISCUSSION
1. What issues do you foresee with this meeting?
2. Do you have specific issues you want us to address, such as regulatory change for simulation,
development of a data forecasting model to understand the regional landscape and guide
decision making?
3. What are your thoughts relative to the state meeting its BSN goals, the Magnet Journey and
training/hiring practices to achieve them?
ACTION REQUESTED
Committee discussion on next steps
Please plan to attend the meeting in your Region
Attachment: Nursing Summit Dates/Locations
BJB:br
Page 59 of 284
Nursing Summits, Fall 2018
INLAND EMPIRE
Date
Time
(Room Availability)
Organization
Location
Monday
September 17
8:00 am – 5:00 pm
Riverside Community
Hospital
4445 Magnolia Avenue
Riverside, CA. 92501
LOS ANGELES
Date
Time
(Room Availability)
Organization
Location
Thursday
September 20
9:30 am – 5:00 pm
UCLA Health
Tamkin Auditorium
Los Angeles, CA
ORANGE COUNTY
Date
Time
(Room Availability)
Organization
Location
Friday
September 21
8:00 am – 5:00 pm
University of California,
Irvine
Podlich Family Conference Center
Irvine, CA
CENTRAL VALLEY
Date
Time
(Room Availability)
Organization
Location
Monday
September 24
7:30 am – 5:00 pm
St. Agnes Medical Center
Administrative Center
1111 E. Spruce Ave.
Plaza – Martin Room, 2nd Floor
Fresno, CA 93720
NORTHERN CALIFORNIA
Date
Time
(Room Availability)
Organization
Location
Tuesday
September 25
7:30 am – 5:30 pm
Sutter Health
Torrey Pines & Calaveras Conference Rooms
2700 Gateway Oaks Drive
Sacramento, CA 95833
BAY AREA
Date
Time
(Room Availability)
Organization
Location
Monday
October 8
8:00 am – 4:30 pm
The California Endowment
2000 Franklin Street
Oakland, CA 94612
SAN DIEGO
Date
Time
(Room Availability)
Organization
Location
Thursday
October 11
9:00 am – 2:00 pm
UC SAN DIEGO HEALTH –
La Jolla
Jacobs Medical Center
Conference Room ECOB 1-001
9300 Campus Point Drive
San Diego, CA 92037
Page 60 of 284
July 25, 2018
TO: CNO Advisory Committee Members
FROM: Kim Tomasi, RN, MSN, CEO, Association of California Nurse Leaders (ACNL)
Marketa Houskova, RN, MAIA, BA, Executive Director, American Nurses Association –
California (ANA-C)
SUBJECT: Advancing Professional Nursing Practice
SUMMARY
The purpose of the CNO Advisory Committee is to advise the CHA Board of Trustees on key policy and
advocacy issues specific to hospital and health system CNOs. A stronger professional nursing voice at
the capital is necessary to thwart activity that prevents advancing professional nursing practice in the
best interest of patient care and the health care needs of our communities. Presently, labor is the only
voice of nursing at the capitol and AB 2759 was an example of a bill that would have impeded our ability
to move forward rapidly with CA BSN educational goals.
ACNL and ANA-C had a joint meeting with their board members in June. There was great discussion and
synergy on how to move the concept of collective nursing policy work forward. Both executive directors
will discuss next steps and outcomes of the meeting.
DISCUSSION
1. How do we enlarge the professional nursing practice voice at the capitol?
2. How do we move to proactive solutions and innovation in nursing practice versus our present
defensive strategies?
3. Can a nursing community composed of nursing organizations interested in this approach make a
difference?
4. What guiding principles could we suggest that would align professional nursing organizations?
ACTION REQUESTED
Feedback to CHA staff on how you would like us to move forward.
Attachments: Nursing Community Coalition
California Nursing Community Spreadsheet
Latest Strategy that Would Reverse Access to Care
Projections of Progress Toward the 80 Percent of Bachelor of Science in Nursing
Recommendation and Strategies to Accelerate Change
BJB:br
Page 61 of 284
For over a decade, the Nursing Community Coalition has been a partnership of national professional nursing
associations that builds consensus and advocates on a wide spectrum of healthcare issues. Collectively, the
Nursing Community is comprised of 58 national nursing organizations that represent the cross section of
education, practice, research, and regulation within the profession. With over four million licensed registered
nurses, advanced practice registered nurses, and nursing students, the profession embodies the drive and passion
to continually improve care for patients, families, and communities across the continuum.
The Nursing Community Coalition supports the following core principles:
• A robust and diverse nursing workforce is essential to the health of all Americans.
• Nurses are an integral part of the healthcare team, are involved in every aspect of care delivery, and are
committed to the patient, their families, the community, and the nation.
• The contributions made by the practice and science of nursing are critical to the delivery of high quality,
life-saving, preventive, and palliative health care across all care settings, geographic areas, and social
determinants of health.
• The services RNs and APRNs provide are linked directly to the availability, cost, and quality of healthcare
services.
• Affordable, accessible, high-quality health care and improved health outcomes depend upon a model of
care that is patient-centered and comprehensive. This can only be achieved through the full complement of
expertise gained from broad-based, inter-professional partnerships of physicians, nurses and other health
professionals.
• Nursing's involvement is essential to the development of new healthcare information technology
infrastructure. Nursing data are key to identifying patient outcomes and required improvements in the
delivery of patient care.
To review the efforts of the Nursing Community Coalition, visit: http://www.thenursingcommunity.org.
Page 62 of 284
The Nursing Community Coalition has supported the following pieces of legislation during the 115th
Congress:
• H.R. 959, S. 1109: Title VIII Nursing Workforce Reauthorization Act of 2017
• S. 445, H.R. 1825: Home Health Care Planning Improvement Act of 2017
• H.R. 3692: Addiction Treatment Access Improvement Act of 2017
The Nursing Community Coalition has submitted testimony to committees on the following issues during the
115th Congress:
• House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related
Agencies to request $244 million for the Title VIII Nursing Workforce Development Programs and
$160 million for the National Institute of Nursing Research for FY 2018.
• Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related
Agencies to request $244 million for the Title VIII Nursing Workforce Development Programs and
$160 million for the National Institute of Nursing Research for FY 2018.
The Nursing Community Coalition has submitted comments on the following issues since the beginning of
the 115th Congress:
• U.S. Department of Veterans Affairs’ final rule published on December 14, 2016 (Federal Register
Document Number 2016-12338, RIN 2900-AP44) regarding Advanced Practice Registered Nurses’
(APRNs) clinical practice within the Veteran’s Health Administration.
• U.S. Department of Health and Human Services’ Draft Strategic Plan for FY 2018 to FY 2022.
• U.S. Department of Veterans Affairs’ proposed rule published on October 2, 2017 that would expand
telehealth services within the Veteran’s Health Administration.
The Nursing Community Coalition has distributed four statements on health reform during the 115th
Congress.
• January 19, 2017: Letter to Congressional Leadership on Health Reform
• January 27, 2017: Letter to Congressional Leadership Outlining Health Priorities
• February 15, 2017: Letter to HHS Secretary Tom Price on Health Reform
• June 22, 2017: Statement to Senators to Commit to America’s Health
The Nursing Community Coalition has hosted events on the following topics:
• Transforming Health and Health Care: Nursing Workforce hosted on May 9, 2017 featured nursing
experts who shared insights on how the profession is meeting the healthcare needs of the nation
and preparing for future demand.
• Transforming Health and Health Care: Nursing Research hosted on May 11, 2017 featured nursing
experts who discussed the contributions of nursing science as it relates to care across the
continuum.
• Future of Nursing: Campaign for Action cohosted with the Robert Wood Johnson Foundation and
the AARP Foundation on September 20, 2017 featured experts working to implement
recommendations from the Institute of Medicine report on the future of nursing.
• The Opioids Crisis: Nursing Practices that Save Lives hosted on December 7, 2017 featured nursing
experts who shared insights and offered solutions to the opioids epidemic facing the country.
Page 63 of 284
4/23/2018
National Organization California Chapters
American Academy of Ambulatory Care Nursing No California Chapters found
American Academy of Nursing No California Chapters found
American Association of Colleges of Nursing No California Chapters found
American Association of Critical-Care Nurses
Chapters in: Fremont, Fresno, Loma Linda, LA, Napa, Oxnard, Rancho Mirage, Sacramento, Salinas, San
Diego, San Francisco, San Jose, Santa Barbara, Tustin, Vallejo, Van Nuys, Whittier
American Association of Heart Failure Nurses No California Chapters found
American Association of Neuroscience Nurses No California Chapters found
American Association of Nurse Anesthetists No California Chapters found
American Association of Nurse Practitioners No California Chapters found
American College of Nurse-Midwives California Nurse-Midwives Association; website: california.midwife.org
American Nephrology Nurses Association
Chapters: SoCal United (Redlands), Sacramento Valley (Rancho Cordova), Chumash (Agoura Hills), San
Joaquin Valley (Friant), Los Angeles (Playa Del Rey), San Francisco Bay Area (Redwood City), Nephros
South (Poway)
American Nurses Association ANA/California: www.anacalifornia.org
American Nursing Informatics Association
Chapters: San Diego (community.ania.org/sandiego/home), SoCal (community.ania.org/socal/home)
American Organization of Nurse Executives Affiliate: Region 9 - ACNL
American Pediatric Surgical Nurses Association No California Chapters found
American Society for Pain Management Nursing
Southern California: Huntington Beach: aspmnsocal.nursingnetwork.com; Northern California: San Jose:
norcalaspmn.org
American Society of PeriAnesthesia Nurses CA liaison: Ernestine Nunes (PANAC) enunesca@aol.com
Association of Community Health Nursing Educators No California Chapters found
Association of Nurses in AIDS Care Chapters: Greater LA; Golden Gate
Association of Pediatric Hematology/Oncology Nurses Chapters: San Francisco Bay Area: baphon.org ; Southern California: scaphon.org
Association of peri-Operative Registered Nurses No California Chapters found
Association of Public Health Nurses
Region 9: AZ, CA, HI, NV - Pamela Dudley, RN - San Luis Obispo County Public Health Department
Association of Veterans Affairs Nurse Anesthetists No California Chapters found
Association of Women's Health, Obstetric and Neonatal Nurses CA Section: AWHONN California: Beth Stephens-Hennessy, Section Chair
Dermatology Nurses' Association Chapter: San Francisco/N. California #004 (melissapcooper@comcast.net)
emergency Nurses Association State Council: EMAIL: ksvandusen@cox.net WEB: http://www.californiaena.org
Friends of the National Institute of Nursing Research Member of Board of directors is in CA but no location in CA that I could find
Gerontological Advanced Practice Nurses Association
CALIFORNIA (Northern)-deborah.baker@ncmahealth.com
CALIFORNIA (Southern)-palomajasmine@msn.com
Hospice and Palliative Nurses Association
California: Deborah Greenspan- please email us at hpna@hpna.org, with “State Ambassador” in the title
line and the name of the person you want to contact.
International Association of Forensic Nurses IAFN Southern California Chapter-CA USA-Chapter #4-acarney@csusm.edu
International Society of Psychiatric-Mental health Nurses No California Chapters found
Page 64 of 284
4/23/2018
National Organization California Chapters
National Association of Clinical Nurse Specialists No California Chapters found
National Association of Neonatal Nurse Practitioners
No California Chapters found
National Association of Neonatal Nurses
Central California (CCANN)
Coastal California (CoCANN)
Inland Counties (ICANN)
Northern California (NCANN)
Southern California (SCANN)
National Association of Nurse Practitioners in Women's Health could not really pull up this site
National Association of Pediatric Nurse Practitioners
LA: http://www.lanapnap.org/home Orange County: https://ocnapnap.enpnetwork.com/
San Diego: http://community.napnap.org/CASANDIEGO/home/
National Black Nurses Association
CA Fresno Central Valley Black Nurses Association (150)
CA Oakland Bay Area Black Nurses Association (2)
CA Los Angeles Council of Black Nurses, Los Angeles (1)
CA Riverside Inland Empire BNA (58)
CA San Diego San Diego Black Nurses Association (3)
national Council of State Boards of Nursing rn.ca.gov/
National Forum of State Nursing Workforce Centers
https://healthimpact.org/
National League for Nursing Associate Members and Member Schools
National Nurse-led Care Consortium No California Chapters found
National Organization of Nurse Practitioner Faculties No California Chapters found
Nurses Organization of Veterans Affairs
120 VA Central California HCS (CA)-140 San Francisco VAMC (CA):Judith Rosen
128 VA Northern California HCS (CA):Need Contact- 129 VA Palo Alto HCS (CA): Carol Valdon
30 VA Greater Los Angels HCS (CA): Heidi Bolling Natlie Meyers
138 VA San Diego HCS (CA):-Carmen Concepcion - 124 VA Loma Linda HCS (CA): Need Contact
126 VA Long Beach HCS (CA): Larry Lemos
Oncology Nursing Society http://sierranevada.vc.ons.org/
Organization for Associate Degree Nursing No California Chapters found
Pediatric Endocrinology Nursing Society Community Area is locked and no listing on webpage
Society of Pediatric Nurses
LA Chapter; Pmueller@chla.usc.edu; Sacramento Chapter ahmarin@UCDAVIS.EDU; Inland Empire
THitchcock@llu.edu; Orange County drea.correia@gmail.com
American Assisted Living Nurses Association (AALNA) No California Chapters found
American Association of Occupational Health Nurses (AAOHN) CA State Chapter- wrobbins@sonnet.ucla.edu
American Psychiatric Nurses Association (APNA) CA Chapter- https://www.apna.org/i4a/pages/index.cfm?pageID=3444
Association of California Nurse Leaders (ACNL) Multiple CA Chapters: http://www.acnl.org/chapters
Association of Rehabilitation Nurses (ARN) LA Chapter http://laocarn.org/
National Organization of Nurses with Disabilities (NOND) website under construction
PeriAnesthesia Nurses Association of California (PANAC) https://panac.nursingnetwork.com/
SEIU Nurse Alliance of California http://www.nurseallianceca.org/
Page 65 of 284
4/23/2018
National Organization California Chapters
Society of Gastroenterology Nurses and Associates, Inc. (SGNA) Northern and Southern Chapters
United Nurses Associations of California/Union of Health Care Profession
http://www.unacuhcp.org/
Wound Ostomy & Continence Nurses Society/Pacific Coast Region Has peer groups not chapters
Page 66 of 284
PROMOTING AMERICA’S HEALTH THROUGH NURSING CARE
www.thenursingcommunity.org · 202-463-6930 ext. 272
Nursing Community Coalition Responds to the American Medical Association’s
Latest Strategy that Would Reverse Access to Care
November 29, 2017−The Nursing Community Coalition (NCC) is disappointed by the American
Medical Association’s (AMA) recent call for action that has the potential to impede access to care by
qualified providers and complicates aspects of an interprofessional, team-based approach.
Specifically, at AMA’s recent House of Delegates Interim meeting, the association adopted an
amended resolution to create a national strategy to obstruct state and national policies that would
allow “non-physician” providers, including Advanced Practice Registered Nurses (APRNs), from
practicing to the full extent of their education, clinical training, and certification. The coalition firmly
believes in the value added to the patient, family, and community through the delivery of care from
all providers practicing to the top of their licensure.
The Institute of Medicine (currently the National Academy of Medicine) calls for the removal of
barriers that prevent APRNs from full practice authority in its pinnacle report Future of Nursing:
Leading Change, Advancing Health.1 This has served as the platform for widespread efforts to
examine scope of practice policies for nearly eight years by stakeholders both within and outside of
professional nursing. Additionally, the Federal Trade Commission has urged states to review laws
and regulations that stifle competition in the healthcare sector, as these impose unnecessary and
burdensome restrictions on APRN practice, which can negatively affect patients.2
The Nursing Community Coalition firmly believes we must work together to put patients first.
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Association of Colleges of Nursing
American Association of Critical-Care Nurses
American Association of Heart Failure Nurses
American Association of Neuroscience Nurses
American Association of Nurse Anesthetists
American Association of Nurse Practitioners
American College of Nurse-Midwives
American Nephrology Nurses Association
American Nurses Association
For any inquiries, please contact Dr. Suzanne Miyamoto, Executive Director of the Nursing
Community Coalition at smiyamoto@aacnnursing.org.
1 Institute of Medicine. (2010). Future of Nursing: Leading Change, Advancing Health. Retrieved from:
http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
2 Federal Trade Commission. (2014). Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses.
Retrieved from: http://www.aacnnursing.org/Portals/42/Policy/PDF/APRN-Policy-Paper.pdf.
Page 67 of 284
American Nursing Informatics Association
American Organization of Nurse Executives
American Pediatric Surgical Nurses Association
American Psychiatric Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association of Community Health Nursing Educators
Association of Nurses in AIDS Care
Association of Pediatric Hematology/Oncology Nurses
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Veterans Affairs Nurse Anesthetists
Association of Women's Health, Obstetric and Neonatal Nurses
Dermatology Nurses' Association
Emergency Nurses Association
Friends of the National Institute of Nursing Research
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
International Association of Forensic Nurses
International Society of Psychiatric-Mental Health Nurses
National Association of Clinical Nurse Specialists
National Association of Neonatal Nurse Practitioners
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women's Health
National Association of Pediatric Nurse Practitioners
National Black Nurses Association
National Council of State Boards of Nursing
National Forum of State Nursing Workforce Centers
National League for Nursing
National Nurse-Led Care Consortium
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Oncology Nursing Society
Organization for Associate Degree Nursing
Pediatric Endocrinology Nursing Society
Society of Pediatric Nurses
Page 68 of 284
Projections of progress toward the 80% Bachelor of
Science in Nursing recommendation and strategies to
accelerate change
Joanne Spetz, PhD*
Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA
ARTICLE INFO
Article history:
Received 23 December 2017
Accepted 29 April 2018
Available online .
Keywords:
Baccalaureate degree
Projection models
Education
ABSTRACT
Background: In 2011, the Institute of Medicine recommended that 80% of RNs have
a bachelor’s degree or higher by 2020. Progress toward this recommendation has
been slow.
Purpose: This paper presents a model that projects whether the 80% recommen-
dation can be met within a 10-year period and estimates the impact of education
changes that might accelerate progress.
Methods: A projection model for 2016 to 2026 was created using a “stock-and-
flow” approach. Secondary data were extracted from multiple sources for the
projections. The model includes the option to enter alternative values of key pa-
rameters to estimate the impact of changes.
Discussion: Based on current patterns of entry-level and RN-to-BSN education, ap-
proximately 66% of RNs are projected to have BSN+education by 2025.
Conclusions: To reach the 80% goal by 2025, changes in the mix of entry-level ed-
ucation and/or an increase in the number of RN-to-BSN graduates will be required.
Cite this article: Spetz, J. (2018, ■■). Projections of progress toward the 80% Bachelor of Science in Nursing
recommendation and strategies to accelerate change. Nursing Outlook, ■■(■■), ■■–■■.https://doi.org/
10.1016/j.outlook.2018.04.012.
In 2011, the Institute of Medicine (IOM, now part of
the National Academy of Science, Engineering, and Med-
icine) released a report, “The Future of Nursing: Leading
Change, Advancing Health,” which contained eight rec-
ommendations regarding how the nursing workforce can
best meet health-care needs in an era of health reform
and population aging (Institute of Medicine, 2011). One
of the most prominent recommendations was that 80%
of Registered Nurses (RNs) have a bachelor’s degree or
higher by 2020. However, progress toward this recom-
mendation has been slow, and it is now widely
recognized that the IOM’s target will take longer than
it recommended. This paper presents a model that
projects whether the 80% recommendation can be met
within a 10-year period and estimates the impact of ed-
ucation changes that might accelerate achievement of
the IOM recommendation.
Nursing is one of a few professions that have mul-
tiple educational paths for entry, with graduates with
nursing diplomas, associate degrees in nursing (ADs),
bachelor’s degrees in nursing (Bachelor of Science in
Nursing [BSN]), and entry-level master’s degrees in
nursing all being qualified to take the national licens-
ing examination. Associate degree education is the most
common among newly graduated nurses, accounting for
about 54% of graduates and about 46% of the total RN
*Corresponding author: Joanne Spetz, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California
Street, Suite 265, San Francisco, CA 94118.
E-mail address: joanne.spetz@ucsf.edu (J. Spetz).
0029-6554/$ — see front matter © 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.outlook.2018.04.012
ARTICLE IN PRESS
Available online at www.sciencedirect.com
Nurs Outlook ■■ (2018) ■■–■■
www.nursingoutlook.org
Page 69 of 284
workforce in 2016 (National Council of State Boards of
Nursing [NCSBN], 2017; U.S. Census Bureau, 2017). Since
1964, the American Nurses’ Association has advocated
that all RNs be required to have a BSN (Dillon, 1997; Friss,
1994; Institute of Medicine, 2011), and in the mid-
1990s the National Advisory Council on Nurse Education
and Practice encouraged policy actions to achieve a
minimum of 66% of RNs having a BSN degree or higher
by 2010 (Aiken, Cheung, & Olds, 2009; Altmann, 2011).
The 2011 IOM recommendation echoed these prior
guidelines, referring to a growing body of research that
linked higher levels of RN education with better patient
outcomes in acute-care settings (Aiken, Clarke, Cheung,
Sloane, & Silber, 2003; Estabrooks, Midodzi, Cummings,
Ricker, & Giovannetti, 2005; Friese, Lake, Aiken, Silber,
& Sochalski, 2008; Kendall-Gallagher, Aiken, Sloane, &
Cimiotti, 2011; Tourangeau et al., 2007; Van den Heede
et al., 2009).
Increases in the share of RNs with BSN and higher
education can result from two trends. First, entry-
level graduates could shift from AD and Diploma
programs to BSN and entry-level master’s degree pro-
grams, thus increasing the numbers of newly licensed
RNs with a BSN degree or higher. There has been such
a trend, with an increase in the share of BSN and higher
degrees among first-time National Council Licensure Ex-
amination (NCLEX) takers from 39.3% in 2010 to 46.2%
in 2016 (NCSBN, 2017). Second, greater numbers of AD
or diploma-educated RNs could pursue a BSN after li-
censure. This also is occurring; the number of RNs
graduating from BSN completion programs has more
than tripled from 19,606 in 2009 to 60,842 in 2016
(American Association of Colleges of Nursing [AACN],
2010–2017).
Despite the shift of entry-level education toward the
BSN and growth in RN-to-BSN graduations, only 54.4%
of all RNs had a BSN degree or higher in 2016 (Campaign
for Action, 2017). Attainment of the 80% target by
2020 will not occur, even though there have been
multipronged efforts nationwide to advance RN edu-
cation (Academic Progression in Nurisng [APIN], 2017)
and a growing number of employers prefer to hire BSN-
educated RNs (AACN, 2014). Projections of the current
trajectory and analysis of the potential impact of dif-
ferent strategies are needed to guide future investments
to accelerate progress.
Data
Data
Secondary data were extracted from the American Com-
munity Survey (ACS), which is an annual survey
conducted by the U.S. Census Bureau to describe the
population of states and the nation (U.S. Census Bureau,
2017). The ACS asks respondents to report their highest
level of education overall and, if they have a bachelor’s
degree or higher, to report their field of study for their
bachelor’s degree. RNs were identified as “BSN+” if their
highest degree was a bachelor’s degree with a nursing
major or a graduate degree with any bachelor’s degree
major. BSN+nurses thus include RNs whose nursing ed-
ucation might not include a bachelor’s degree but who
have a graduate degree and work as an RN. The numbers
of RNs with BSN+and other education were calcu-
lated in 10-year age groups from the ACS for the nation
and each state. In addition, state websites were searched
to identify whether state-level organizations reported
data from their own surveys about RN education levels;
these data were used if the data were more recent or
had a smaller margin of error than the ACS.
The number of new entrants to the nursing profes-
sion was estimated from NCSBN reports on the number
of first-time NCLEX-RN takers, by type of degree (NCSBN,
2017). The number of graduates of RN-to-BSN pro-
grams was provided by the AACN (AACN, 2010–2017).
These data sources do not provide information about
the age distribution of test-takers and graduates. Data
from the California Board of Registered Nursing 2015–
2016 Annual Schools Survey were used to obtain the age
distribution of graduates of AD and of BSN programs
(Blash, Shinoki, & Spetz, 2017). Data from the Califor-
nia Board of Registered Nursing Survey of RN Education
Experiences were used to estimate the age distribu-
tion of graduates from RN-to-BSN programs (Spetz, Chu,
Blash, Lin, & Keane, 2014).
Methods
A projection model was created using a “stock-and-
flow” approach (Bruni, 1988). The “stock” is the number
of RNs available and the “flows” are RNs moving into
and out of the stock. Figure 1 illustrates the model used
for this study. There are stocks of BSN+RNs (pink ovals)
and other RNs (green ovals) in 10-year age groups. The
inflows are newly licensed RNs who can enter any of
the education-age groups, indicated by the orange boxes
and arrows. The outflows are RNs moving into older age
groups or leaving the labor market from the oldest age
group. RNs also can move from the non-BSN+stock to
the BSN+stock upon completion of post-licensure ed-
ucation, as indicated by the pink arrows.
The model begins with 2016 data and then esti-
mates the stocks for 2-year increments. Every 2 years,
20% of each age group moves to the next age group, as-
suming that RNs’ ages are evenly distributed within the
10-year age groups (blue arrows), and newly gradu-
ated RNs are added to the stock. For the youngest age
group (30 years and younger), it is assumed that 40%
move to the next age group every 2 years because this
age group is predominantly composed of RNs 26 to 30
years old. For the oldest age group (61 years and older),
it is assumed that 30% leave the labor force every 2 years,
which is consistent with data used in California’s fore-
casts of RN supply (Spetz, 2017).
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The calculations are iterated four times to obtain pro-
jections 10 years into the future. The projections are
computed in an Excel workbook, which is available
online (http://rnworkforce.ucsf.edu) and includes the
option to enter alternative values of key parameters
such as the numbers of newly graduated nurses in each
age-education group and the number of RN-to-BSN
graduates.
This model has a number of limitations. First, it does
not model inflows of internationally educated RNs, many
of whom have bachelor’s degrees. Second, it does not
include outflows of RNs who choose to leave the pro-
fession at younger ages or move to other countries.Third,
the data from California used to estimate the age dis-
tribution of newly graduated RNs may not match the
national age distribution owing to unique characteris-
tics of the RN education system in that state. Fourth,
this model does not account for internationally edu-
cated RNs, most of whom have baccalaureate-level
education. Changes in rates of international recruit-
ment may increase or diminish the overall share of RNs
with a BSN. Fifth, the model assumes that RN employ-
ment is constant over RNs’ lifetimes and does not project
changes in the stock of nurses as some choose to stop
working at various stages of their lives. The omission
of these factors was deliberate to ensure a straightfor-
ward model design, which is useful for general planning
purposes. The results should not be considered precise.
Findings
In 2016, 54.4% of RNs had a bachelor’s in nursing or grad-
uate degree (BSN+). Based on current patterns of entry-
level and RN-to-BSN education, approximately 66% of
RNs are projected to have BSN+education by 2025
(Figure 2).
Figure 1 – Stock-and-flow model of the RN workforce. AD, associate degree; BSN, Bachelor of Science in
Nursing; RN, Registered Nurse. (Color version available online.)
Figure 2 – Projected percent of nurses with Bachelor of Science in Nursing or higher education.
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Page 71 of 284
To reach the 80% goal by 2025, changes in the mix
of entry-level education and/or an increase in the
number of RN-to-BSN graduates will be required. Figure 3
presents projections if the share of newly entering RNs
with BSN+education rises immediately from the current
46% to 70%. In this scenario, nearly three quarters of
RNs would have BSN+education by 2026, which is still
short of the IOM recommendation.
Another approach is to have more nurses pursue post-
licensure baccalaureate education. As seen in Figure 4,
if the number of RN-to-BSN graduates rose to 100,000
per year, 75% of RNs would have BSN+education in 2026.
Figure 5 combines the scenarios presented in Figures 3
and 4, with 70% of new graduates having BSN+educa-
tion and 100,000 RN-to-BSN graduates per year. In this
projection, the share of RNs with BSN+education would
be 79% in 2024 and nearly 84% in 2026.
Discussion
Since the IOM Future of Nursing report, numerous ad-
ditional studies have confirmed that more RNs need to
attain at least a bachelor’s degree to meet future health-
care needs (Blegen, Goode, Park, Vaughn, & Spetz, 2013;
Cho et al., 2015; Kutney-Lee, Sloane, & Aiken, 2013;
Yakusheva, Lindrooth, & Weiss, 2014a, 2014b; You et al.,
2013). In addition, employers have demonstrated a strong
preference for hiring BSN-educated nurses (AACN, 2014).
Figure 3 – Projected percent of nurses with BSN or higher education if 70% of new graduates have a BSN or
master’s degree. BSN, Bachelor of Science in Nursing.
Figure 4 – Projected percent of nurses with Bachelor of Science in Nursing or higher education if the number
of Registered Nursing-to-Bachelor of Science in Nursing graduates increases to 100,000 per year.
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Page 72 of 284
Despite this, progress toward the IOM recommenda-
tion has been slow. More than half of entry-level RN
graduates have an AD and, while many want to obtain
a BSN, there is not sufficient capacity in entry-level BSN
or RN-to-BSN programs to reach the IOM recommen-
dation in the foreseeable future.
Most states are faring no better than the nation. In
2016, no state had reached the 80% target; in fact, none
had reached even 70% by 2016. Only 11 states—Alaska,
Colorado, Delaware, Hawaii, Idaho, Kansas, Michigan,
Minnesota, Nebraska, New Jersey, North Dakota—and
the District of Columbia have at least 60% of their RNs
at the BSN+level of education (U.S. Census Bureau, 2017;
state-specific data obtained by author).
The projection model developed for this study helps
identify the key reasons that progress has been and is
likely to remain slow toward attaining the IOM’s rec-
ommendation. The main factor affecting progress is the
large incumbent RN workforce. There are over 3.3 million
RNs in the United States, and the 157,143 people who
took the NCLEX for the first time in 2016 are only 4.7%
of the size of the total workforce. The 60,842 RN-to-
BSN graduates are only 1.8% of the workforce. These
numbers are small compared with the total work-
force, and even large changes in the number of new and
post-licensure BSN graduates will have small effects on
the overall share of RNs with BSN+education.
There may also be reluctance on the part of some RNs
to pursue post-licensure BSN education. A survey
conducted in 2013 of California RNs reported that
13.4% was “seriously considering” pursuing additional
education, but nearly 60% was “not at all” considering
additional education. Younger RNs were more likely to
consider additional education, which is not surpris-
ing. Among those who were not interested in continuing
their education, the most important reasons cited were
as follows: believing they were too old to return to school
(36.3%), not having enough time for school (29.9%), not
believing additional education was needed to provide
good patient care (29.9%), and higher education not
being relevant to their career plans (28.6%). Nurses in
other states may have different perspectives regard-
ing continuing their education; it should be noted that
California’s nurses work in a heavily unionized envi-
ronment and have implicit job protection associated with
the state’s minimum nurse-to-patient hospital staff-
ing requirements, both of which may diminish the value
of the BSN for California nurses.
Recent research found that completing an RN-to-
BSN program 5 years after finishing the initial AD
education increases lifetime earnings between 2.6% and
5.1%, and that the gain for finishing an RN-to-BSN 10
years after initial education is smaller but still posi-
tive (Spetz & Bates, 2013). Other reasons for RNs to
pursue additional education, as reported by the Cali-
fornia survey, include personal fulfillment, the desire to
gain new nursing skills to improve the quality of care,
interest in updating knowledge of nursing practice,
and interest in becoming an advanced practice RN. In
that survey, a number of nurses noted in the narrative
comments that they would like to pursue additional ed-
ucation but were still paying loans from their initial RN
degree. About 8% of those providing comments felt that
additional education would not yield enough return on
investment to justify the cost.
Amplified efforts are needed to attain the IOM goal
of 80% of RNs having BSN or higher education by 2026,
or even by 2030. Increasing RN-to-BSN education op-
portunities is likely to have the greatest impact because
it allows incumbent nurses the ability to attain a BSN.
Many nurses work while they pursue RN-to-BSN edu-
cation, which makes it financially feasible to return to
school. A growing number of employers offer tuition re-
imbursement to support RN-to-BSN and graduate-level
Figure 5 – Projected percent of nurses with Bachelor of Science in Nursing (BSN) or higher education if 70% of
new Registered Nurse (RN) graduates have a BSN or higher degree and the number of RN-to-BSN graduates
increases to 100,000 per year.
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education, and some have developed partnerships with
colleges to facilitate post-licensure education (Hendricks
et al., 2012; Murray, Havener, Davis, Jastremski, &
Twichell, 2011; Sportsman & Allen, 2011; Zimmermann,
Miner, & Zittel, 2010). Some employers require that newly
hired RNs with associate degrees obtain a bachelor’s
degree within a specified amount of time (Chu, Spetz,
& Bates, 2018) and, in 2017, the governor of New York
signed Senate Bill 6768, which requires that RNs achieve
a bachelor’s degree within 10 years of licensure to main-
tain their license (State of New York, 2017).
Policies that encourage the pursuit of initial BSN
degrees also need to be supported. Many nurses select
AD entry-level education because it is inexpensive and
geographically convenient, especially for rural stu-
dents. A growing number of community colleges are
now offering baccalaureate degrees, including in nursing,
and this has been shown to increase both the total
number of nurses produced and their education level
(Daun-Barnett, 2011). Baccalaureate entry-level pro-
grams can expand part-time offerings and work with
community colleges to offer BSN-level education at
remote sites. Such a strategy is being pursued in New
Mexico, for which the University of New Mexico is col-
laborating with rural community colleges to offer BSN
entry-level degrees.
Although the IOM target of 80% of RNs having
BSN+education will not be met by 2020, notable pro-
gress has been made toward this goal. The number of
RNs graduating from RN-to-BSN programs has more than
tripled, and entry-level students are shifting toward BSN
and entry-level master’s programs. Employers are in-
creasingly rewarding RNs for completing additional
education. The main beneficiaries of amplified work
toward the IOM recommendation will be health-care
consumers, who will receive care from nurses prepared
to address complex health-care needs in collaborative
health-care teams.
Acknowledgments
Timothy Bates, Matthew Jura, and Ginachuwku Amah
provided assistance in data extraction from secondary
sources. Bryan Hoffman provided feedback at various
stages of the project.
Funding: This work was supported by the American
Organization of Nurse Executives through a contract pro-
vided to the author. The original source of funding to
AONE was the Robert Wood Johnson Foundation.
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Sermeus, W. (2013). Hospital nursing, care quality, and patient
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ARTICLE IN PRESS
7Nurs Outlook ■■ (2018) ■■–■■
Page 75 of 284
July 25, 2018
TO: CNO Advisory Committee Members
FROM: Debby Rogers, RN, MS, FAEN, Vice President, Clinical Performance and Transformation
SUBJECT: Parkinson’s and SB 1288 Update
SUMMARY
Parkinson’s Registry
A new state law requires health care providers diagnosing or treating Parkinson’s disease patients to
report each case to the California Department of Public Health (CDPH) beginning July 1. The state is
establishing the California Parkinson’s Disease Registry, a statewide population-based registry that will
measure the incidence and prevalence of Parkinson’s disease. CDPH intends to use the information to
improve the lives of those affected by the disease.
CDPH recently issued an implementation guide that includes the necessary specifications for reporting
Parkinson’s disease data and outlines who is required to report, the timing of reporting and the methods
for transmitting data. CHA is seeking clarification on some of the elements in the implementation guide
and will share more information with members when available. CDPH will host informational meetings
in May. For more information, visit the CDPH website.
SB 1288 (Leyva, D-Chino)
This bill would establish a separate penalty structure for citations issued by the California Department of
Public Health (CDPH) for violation of nurse-to-patient regulations. Penalties for the first and second
violations would range from $2,500 to $25,000, the third violation penalty would be $75,000, the fourth
violation penalty would range from $75,000 to $100,000 and all subsequent violations would be
assessed at $125,000
Most hospitals surveyed are able to meet staffing ratios 90-95% of the time (see attachment), but
despite rigorous attention to staffing and flexible staffing plans, the “at all times” is almost impossible to
attain 100% of the time.
DISCUSSION
1. What are some of the elements on the Parkinson’s data base that are being questioned?
2. How will CDPH be made aware of staffing ratio infringement and would there be an
investigatory review by CDPH to affirm the validity of the issue?
ACTION REQUESTED
Information only.
Page 76 of 284
Parkinson’s and Cancer Registry Update
July 25, 2018
Page 2
Attachments: SB 1288
Staffing Ratio Compliance survey results
BJB:br
Page 77 of 284
AMENDED IN ASSEMBLY JUNE 21, 2018
AMENDED IN SENATE APRIL 25, 2018
SENATE BILL No. 1288
Introduced by Senator Leyva
(Coauthor: Assembly Member Santiago)
(Coauthor: Senator Jackson)
(Coauthors: Assembly Members Bonta, Rodriguez, and Santiago)
February 16, 2018
An act to amend Sections 1279, 1280.2, 1280.3, 1280.6, and 1280.15
of, and to repeal Section 1280.1 of, the Health and Safety Code, relating
to health and care facilities.
legislative counsel’s digest
SB 1288, as amended, Leyva. Health and care facilities: inspections.
Existing law establishes the State Department of Public Health and
sets forth its powers and duties, including, but not limited to, the
licensing and regulation of health facilities, as defined. Existing law
requires that every health facility for which a license or special permit
has been issued be periodically inspected by the State Department of
Public Health, or by another governmental entity under contract with
the department. Existing law requires the department to inspect those
facilities for compliance with provisions of state law and regulations
during a state periodic inspection, or at the same time as a federal
periodic inspection.
Existing law requires the department to adopt regulations governing
the operation of a health facility, including, but not limited to,
regulations that require prescribed health facilities to meet minimum
nurse-to-patient ratios, and to assign additional staff according to a
documented patient classification system for determining nursing care
97
Page 78 of 284
requirements. Violation of these provisions, or willful or repeated
violation of the rules or regulations, is a crime.
This bill would require state periodic inspections of health facilities
to include reviews of compliance with the nurse-to-patient ratios and
staff assignment regulations described above. The bill would require
the department to ensure that these inspections are not announced in
advance of the date of inspection.
Existing law requires the department to promulgate regulations
establishing criteria to assess an administrative penalty against a general
acute care hospital, acute psychiatric hospital, or special hospital. Until
the effective date of specified regulations, existing law authorizes the
department to assess the licensee an administrative penalty not to exceed
$100,000, as specified, when a licensee of a hospital receives a notice
of deficiency constituting an immediate jeopardy to the health or safety
of a patient and is required to submit a plan of correction. After the
effective date of these specified regulations, existing law authorizes the
department to assess administrative penalties not to exceed $125,000,
as specified.
Existing law requires certain penalties collected by the department
to be deposited into the Internal Departmental Quality Improvement
Account, to be expended, upon appropriation, for internal quality
improvement activities in the Licensing and Certification Program.
This bill would repeal the obsolete provisions that authorize the
assessment of administrative penalties not to exceed $100,000 until
specified regulations are adopted. The bill, notwithstanding the latter
administrative penalty provisions described above, would instead require
the department to assess specified penalties not to exceed $125,000 for
violations of the nurse-to-patient ratios and staff assignment regulations
described above and above. The bill would require those penalty moneys
to be deposited into the State Department of Public Health Licensing
and Certification Program Fund, to be expended, upon appropriation,
for the purpose of enforcing those regulations. The bill would specify
that a violation of these regulations is not a crime. The bill would also
make technical and conforming changes.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
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The people of the State of California do enact as follows:
line 1 SECTION 1. Section 1279 of the Health and Safety Code is
line 2 amended to read:
line 3 1279. (a) Every health facility for which a license or special
line 4 permit has been issued shall be periodically inspected by the
line 5 department, or by another governmental entity under contract with
line 6 the department. The frequency of inspections shall vary, depending
line 7 upon the type and complexity of the health facility or special
line 8 service to be inspected, unless otherwise specified by state or
line 9 federal law or regulation. The inspection shall include participation
line 10 by the California Medical Association consistent with the manner
line 11 in which it participated in inspections, as provided in Section 1282
line 12 prior to September 15, 1992.
line 13 (b) Except as provided in subdivision (c), inspections shall be
line 14 conducted no less than once every two years and as often as
line 15 necessary to ensure the quality of care being provided.
line 16 (c) For a health facility specified in subdivision (a), (b), or (f)
line 17 of Section 1250, inspections shall be conducted no less than once
line 18 every three years, and as often as necessary to ensure the quality
line 19 of care being provided.
line 20 (d) During the inspection, the representative or representatives
line 21 shall offer such advice and assistance to the health facility as they
line 22 deem appropriate.
line 23 (e) For acute care hospitals of 100 beds or more, the inspection
line 24 team shall include at least a physician, registered nurse, and persons
line 25 experienced in hospital administration and sanitary inspections.
line 26 During the inspection, the team shall offer advice and assistance
line 27 to the hospital as it deems appropriate.
line 28 (f) The department shall ensure that a periodic inspection
line 29 conducted pursuant to this section is not announced in advance of
line 30 the date of inspection. An inspection may be conducted jointly
line 31 with inspections by entities specified in Section 1282. However,
line 32 if the department conducts an inspection jointly with an entity
line 33 specified in Section 1282 that provides notice in advance of the
line 34 periodic inspection, the department shall conduct an additional
line 35 periodic inspection that is not announced or noticed to the health
line 36 facility. The department shall ensure that a periodic inspection
line 37 conducted to inspect compliance with regulations adopted pursuant
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line 1 to Section 1276.4 is not announced in advance of the date of
line 2 inspection.
line 3 (g) Notwithstanding any other provision of law, the department
line 4 shall inspect the facility for compliance with provisions of state
line 5 law and regulations during a state periodic inspection or at the
line 6 same time as a federal periodic inspection, including, but not
line 7 limited to, an inspection required under this section. Inspections
line 8 conducted pursuant to this section shall include reviews of
line 9 compliance with regulations adopted pursuant to Section 1276.4.
line 10 If the department inspects for compliance with state law and
line 11 regulations at the same time as a federal periodic inspection, the
line 12 inspection shall be done consistent with the guidance of the federal
line 13 Centers for Medicare and Medicaid Services for the federal portion
line 14 of the inspection.
line 15 (h) The department shall emphasize consistency across the state
line 16 and its district offices when conducting licensing and certification
line 17 surveys and complaint investigations, including the selection of
line 18 state or federal enforcement remedies in accordance with Section
line 19 1423. The department may issue federal deficiencies and
line 20 recommend federal enforcement actions in those circumstances
line 21 where they provide more rigorous enforcement action.
line 22 SEC. 2. Section 1280.1 of the Health and Safety Code is
line 23 repealed.
line 24 SEC. 3. Section 1280.2 of the Health and Safety Code is
line 25 amended to read:
line 26 1280.2. (a) No deficiency cited pursuant to paragraph (2) of
line 27 subdivision (b) of Section 1280 shall be for the failure of a facility
line 28 to meet the requirements of the California Building Standards
line 29 Code if, as of January 1, 1994, the hospital building was approved
line 30 under Chapter 12.5 (commencing with Section 15000) of Division
line 31 12.5, or if the hospital building was exempt from that approval
line 32 under any other provision of law in effect on that date.
line 33 (b) It is the intent of the Legislature that the amendments made
line 34 to Section 1280 by the act that added this section shall not be
line 35 construed to require the retrofitting of hospital buildings built prior
line 36 to January 1, 1994, to meet seismic standards in effect on that date.
line 37 SEC. 4. Section 1280.3 of the Health and Safety Code is
line 38 amended to read:
line 39 1280.3. (a) Commencing on the effective date of the
line 40 regulations adopted pursuant to this section, the director may assess
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line 1 an administrative penalty against a licensee of a health facility
line 2 licensed under subdivision (a), (b), or (f) of Section 1250 for a
line 3 deficiency constituting an immediate jeopardy violation as
line 4 determined by the department up to a maximum of seventy-five
line 5 thousand dollars ($75,000) for the first administrative penalty, up
line 6 to one hundred thousand dollars ($100,000) for the second
line 7 subsequent administrative penalty, and up to one hundred
line 8 twenty-five thousand dollars ($125,000) for the third and every
line 9 subsequent violation. An administrative penalty issued after three
line 10 years from the date of the last issued immediate jeopardy violation
line 11 shall be considered a first administrative penalty so long as the
line 12 facility has not received additional immediate jeopardy violations
line 13 and is found by the department to be in substantial compliance
line 14 with all state and federal licensing laws and regulations. The
line 15 department shall have full discretion to consider all factors when
line 16 determining the amount of an administrative penalty pursuant to
line 17 this section.
line 18 (b) Except as provided in subdivision (c), for a violation of this
line 19 chapter or the rules and regulations promulgated thereunder that
line 20 does not constitute a violation of subdivision (a), the department
line 21 may assess an administrative penalty in an amount of up to
line 22 twenty-five thousand dollars ($25,000) per violation. This
line 23 subdivision shall also apply to violation of regulations set forth in
line 24 Article 1 (commencing with Section 127400) of Chapter 2.5 of
line 25 Part 2 of Division 107 or the rules and regulations promulgated
line 26 thereunder.
line 27 The department shall promulgate regulations establishing the
line 28 criteria to assess an administrative penalty against a health facility
line 29 licensed pursuant to subdivisions subdivision (a), (b), or (f) of
line 30 Section 1250. The criteria shall include, but need not be limited
line 31 to, the following:
line 32 (1) The patient’s physical and mental condition.
line 33 (2) The probability and severity of the risk that the violation
line 34 presents to the patient.
line 35 (3) The actual financial harm to patients, if any.
line 36 (4) The nature, scope, and severity of the violation.
line 37 (5) The facility’s history of compliance with related state and
line 38 federal statutes and regulations.
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line 1 (6) Factors beyond the facility’s control that restrict the facility’s
line 2 ability to comply with this chapter or the rules and regulations
line 3 promulgated thereunder.
line 4 (7) The demonstrated willfulness of the violation.
line 5 (8) The extent to which the facility detected the violation and
line 6 took steps to immediately correct the violation and prevent the
line 7 violation from recurring.
line 8 (c) The department shall not assess an administrative penalty
line 9 for minor violations.
line 10 (d) The regulations shall not change the definition of immediate
line 11 jeopardy as established in this section.
line 12 (e) The regulations shall apply only to incidents occurring on
line 13 or after the effective date of the regulations.
line 14 (f) (1) Notwithstanding subdivision (a), if a health facility
line 15 licensed pursuant to subdivision (a), (b), or (f) of Section 1250 is
line 16 issued a citation for violating a regulation adopted pursuant to
line 17 Section 1276.4, the department shall assess an administrative
line 18 penalty in an amount not less than two thousand five hundred
line 19 dollars ($2,500) and not to exceed twenty-five thousand dollars
line 20 ($25,000) for the first and second violation. For a third violation,
line 21 the department shall assess an administrative penalty of not less
line 22 than twenty-five thousand dollars ($25,000) and not to exceed
line 23 seventy-five thousand dollars ($75,000). For a fourth violation,
line 24 the department shall assess an administrative penalty of not less
line 25 than seventy-five thousand dollars ($75,000) and not to exceed
line 26 one hundred thousand dollars ($100,000). The department shall
line 27 assess an administrative penalty of one hundred twenty-five
line 28 thousand dollars ($125,000) for each subsequent violation. For
line 29 purposes of this subdivision, multiple violations found on the same
line 30 inspection survey shall constitute a single violation for purposes
line 31 of determining whether the violation was a first, second, third,
line 32 fourth, or subsequent violation.
line 33 (2) This subdivision shall not be construed to abrogate
line 34 subdivision (a).
line 35 (3) Notwithstanding Section 1290, a violation of a regulation
line 36 adopted pursuant to Section 1276.4 shall not constitute a crime.
line 37 (4) Notwithstanding subdivision (f) of Section 1280.15, all
line 38 penalties collected by the department pursuant to paragraph (1)
line 39 shall be deposited into the State Department of Public Health
line 40 Licensing and Certification Program Fund, under Section 1266.9.
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line 1 These penalty revenues shall be expended solely for the purpose
line 2 of enforcing regulations adopted pursuant to Section 1276.4.
line 3 (g) If the licensee disputes a determination by the department
line 4 regarding the alleged deficiency or alleged failure to correct a
line 5 deficiency, or regarding the reasonableness of the proposed
line 6 deadline for correction or the amount of the penalty, the licensee
line 7 may, within 10 working days, request a hearing pursuant to Section
line 8 131071. Penalties shall be paid when all appeals have been
line 9 exhausted and the department’s position has been upheld.
line 10 (h) For purposes of this section, “immediate jeopardy” means
line 11 a situation in which the licensee’s noncompliance with one or more
line 12 requirements of licensure has caused, or is likely to cause, serious
line 13 injury or death to the patient.
line 14 (i) In enforcing subdivision (a) the department shall take into
line 15 consideration the special circumstances of small and rural hospitals,
line 16 as defined in Section 124840, in order to protect access to quality
line 17 care in those hospitals.
line 18 SEC. 5. Section 1280.6 of the Health and Safety Code is
line 19 amended to read:
line 20 1280.6. In assessing an administrative penalty pursuant to
line 21 Section 1280.3 against a licensee of a health facility licensed under
line 22 subdivision (a) of Section 1250 owned by a nonprofit corporation
line 23 that shares an identical board of directors with a nonprofit health
line 24 care service plan licensed pursuant to Chapter 2.2 (commencing
line 25 with Section 1340), the director shall consider whether the
line 26 deficiency arises from an incident that is the subject of investigation
line 27 of, or has resulted in a fine to, the health care service plan by the
line 28 Department of Managed Health Care. If the deficiency results from
line 29 the same incident, the director shall limit the administrative penalty
line 30 to take into consideration the penalty imposed by the Department
line 31 of Managed Health Care.
line 32 SEC. 6. Section 1280.15 of the Health and Safety Code is
line 33 amended to read:
line 34 1280.15. (a) A clinic, health facility, home health agency, or
line 35 hospice licensed pursuant to Section 1204, 1250, 1725, or 1745
line 36 shall prevent unlawful or unauthorized access to, and use or
line 37 disclosure of, patients’ medical information, as defined in Section
line 38 56.05 of the Civil Code and consistent with Section 1280.18. For
line 39 purposes of this section, internal paper records, electronic mail,
line 40 or facsimile transmissions inadvertently misdirected within the
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line 1 same facility or health care system within the course of
line 2 coordinating care or delivering services shall not constitute
line 3 unauthorized access to, or use or disclosure of, a patient’s medical
line 4 information. The department, after investigation, may assess an
line 5 administrative penalty for a violation of this section of up to
line 6 twenty-five thousand dollars ($25,000) per patient whose medical
line 7 information was unlawfully or without authorization accessed,
line 8 used, or disclosed, and up to seventeen thousand five hundred
line 9 dollars ($17,500) per subsequent occurrence of unlawful or
line 10 unauthorized access, use, or disclosure of that patient’s medical
line 11 information. For purposes of the investigation, the department
line 12 shall consider the clinic’s, health facility’s, agency’s, or hospice’s
line 13 history of compliance with this section and other related state and
line 14 federal statutes and regulations, the extent to which the facility
line 15 detected violations and took preventative action to immediately
line 16 correct and prevent past violations from recurring, and factors
line 17 outside its control that restricted the facility’s ability to comply
line 18 with this section. The department shall have full discretion to
line 19 consider all factors when determining whether to investigate and
line 20 the amount of an administrative penalty, if any, pursuant to this
line 21 section.
line 22 (b) (1) A clinic, health facility, home health agency, or hospice
line 23 to which subdivision (a) applies shall report any unlawful or
line 24 unauthorized access to, or use or disclosure of, a patient’s medical
line 25 information to the department no later than 15 business days after
line 26 the unlawful or unauthorized access, use, or disclosure has been
line 27 detected by the clinic, health facility, home health agency, or
line 28 hospice.
line 29 (2) Subject to subdivision (c), a clinic, health facility, home
line 30 health agency, or hospice shall also report any unlawful or
line 31 unauthorized access to, or use or disclosure of, a patient’s medical
line 32 information to the affected patient or the patient’s representative
line 33 at the last known address, or by an alternative means or at an
line 34 alternative location as specified by the patient or the patient’s
line 35 representative in writing pursuant to Section 164.522(b) of Title
line 36 45 of the Code of Federal Regulations, no later than 15 business
line 37 days after the unlawful or unauthorized access, use, or disclosure
line 38 has been detected by the clinic, health facility, home health agency,
line 39 or hospice. Notice may be provided by email only if the patient
line 40 has previously agreed in writing to electronic notice by email.
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line 1 (c) (1) A clinic, health facility, home health agency, or hospice
line 2 shall delay the reporting, as required pursuant to paragraph (2) of
line 3 subdivision (b), of any unlawful or unauthorized access to, or use
line 4 or disclosure of, a patient’s medical information beyond 15
line 5 business days if a law enforcement agency or official provides the
line 6 clinic, health facility, home health agency, or hospice with a written
line 7 or oral statement that compliance with the reporting requirements
line 8 of paragraph (2) of subdivision (b) would likely impede the law
line 9 enforcement agency’s investigation that relates to the unlawful or
line 10 unauthorized access to, and use or disclosure of, a patient’s medical
line 11 information and specifies a date upon which the delay shall end,
line 12 not to exceed 60 days after a written request is made, or 30 days
line 13 after an oral request is made. A law enforcement agency or official
line 14 may request an extension of a delay based upon a written
line 15 declaration that there exists a bona fide, ongoing, significant
line 16 criminal investigation of serious wrongdoing relating to the
line 17 unlawful or unauthorized access to, and use or disclosure of, a
line 18 patient’s medical information, that notification of patients will
line 19 undermine the law enforcement agency’s investigation, and that
line 20 specifies a date upon which the delay shall end, not to exceed 60
line 21 days after the end of the original delay period.
line 22 (2) If the statement of the law enforcement agency or official
line 23 is made orally, then the clinic, health facility, home health agency,
line 24 or hospice shall do both of the following:
line 25 (A) Document the oral statement, including, but not limited to,
line 26 the identity of the law enforcement agency or official making the
line 27 oral statement and the date upon which the oral statement was
line 28 made.
line 29 (B) Limit the delay in reporting the unlawful or unauthorized
line 30 access to, or use or disclosure of, the patient’s medical information
line 31 to the date specified in the oral statement, not to exceed 30 calendar
line 32 days from the date that the oral statement is made, unless a written
line 33 statement that complies with the requirements of this subdivision
line 34 is received during that time.
line 35 (3) A clinic, health facility, home health agency, or hospice
line 36 shall submit a report that is delayed pursuant to this subdivision
line 37 not later than 15 business days after the date designated as the end
line 38 of the delay.
line 39 (d) If a clinic, health facility, home health agency, or hospice
line 40 to which subdivision (a) applies violates subdivision (b), the
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line 1 department may assess the licensee a penalty in the amount of one
line 2 hundred dollars ($100) for each day that the unlawful or
line 3 unauthorized access, use, or disclosure is not reported to the
line 4 department or the affected patient, following the initial 15-day
line 5 period specified in subdivision (b). However, the total combined
line 6 penalty assessed by the department under subdivision (a) and this
line 7 subdivision shall not exceed two hundred fifty thousand dollars
line 8 ($250,000) per reported event. For enforcement purposes, it shall
line 9 be presumed that the facility did not notify the affected patient if
line 10 the notification was not documented. This presumption may be
line 11 rebutted by a licensee only if the licensee demonstrates, by a
line 12 preponderance of the evidence, that the notification was made.
line 13 (e) In enforcing subdivisions (a) and (d), the department shall
line 14 take into consideration the special circumstances of small and rural
line 15 hospitals, as defined in Section 124840, and primary care clinics,
line 16 as defined in subdivision (a) of Section 1204, in order to protect
line 17 access to quality care in those hospitals and clinics. When assessing
line 18 a penalty on a skilled nursing facility or other facility subject to
line 19 Section 1423, 1424, 1424.1, or 1424.5, the department shall issue
line 20 only the higher of either a penalty for the violation of this section
line 21 or a penalty for violation of Section 1423, 1424, 1424.1, or 1424.5,
line 22 not both.
line 23 (f) All penalties collected by the department pursuant to this
line 24 section, 1280.3, and Sections 1280.3 and 1280.4, shall be deposited
line 25 into the Internal Departmental Quality Improvement Account,
line 26 which is hereby created within the Special Deposit Fund under
line 27 Section 16370 of the Government Code. Upon appropriation by
line 28 the Legislature, moneys in the account shall be expended for
line 29 internal quality improvement activities in the Licensing and
line 30 Certification Program.
line 31 (g) If the licensee disputes a determination by the department
line 32 regarding a failure to prevent or failure to timely report unlawful
line 33 or unauthorized access to, or use or disclosure of, patients’ medical
line 34 information, or the imposition of a penalty under this section, the
line 35 licensee may, within 10 days of receipt of the penalty assessment,
line 36 request a hearing pursuant to Section 131071. Penalties shall be
line 37 paid when appeals have been exhausted and the penalty has been
line 38 upheld.
line 39 (h) In lieu of disputing the determination of the department
line 40 regarding a failure to prevent or failure to timely report unlawful
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Page 87 of 284
line 1 or unauthorized access to, or use or disclosure of, patients’ medical
line 2 information, transmit to the department 75 percent of the total
line 3 amount of the administrative penalty, for each violation, within
line 4 30 business days of receipt of the administrative penalty.
line 5 (i) For purposes of this section, the following definitions shall
line 6 apply:
line 7 (1) “Reported event” means all breaches included in any single
line 8 report that is made pursuant to subdivision (b), regardless of the
line 9 number of breach events contained in the report.
line 10 (2) “Unauthorized” means the inappropriate access, review, or
line 11 viewing of patient medical information without a direct need for
line 12 medical diagnosis, treatment, or other lawful use as permitted by
line 13 the Confidentiality of Medical Information Act (Part 2.6
line 14 (commencing with Section 56) of Division 1 of the Civil Code)
line 15 or any other statute or regulation governing the lawful access, use,
line 16 or disclosure of medical information.
O
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Atalltimes 90% 75% 50% Other Comments
no yes
no yes
yes yes yes yes
The"atalltimes"isthemostchallengingasitinlcudes10
minuterestperiods.Ifwearenotabletofindareplacementto
coverthenursethesebreaks,theRNdoesnotleaveandwepay
a"missedmealbreakpenalty"forthatperiodoftimetothe
individualRN.
no yes
prettyconsistently90%ofthetime‐issuesasyouwouldexpect
with"atalltimes".
no yes
Ourchargenursesoftentakepatients‐thusourbreakreliefis
impactedbymanyofourCAfacilities.
no yes
WedoreceiveADOs.Fortunatelyrelativelyinfrequently.This
calendaryearwehave10,lastcalendaryearwehad35.Some
ofthemarerelatedtonotbeingabletotaketheirbreaks,that
wouldnotallowthemtostafftoratio/acuity.InotherADOs,
thestaffingwassupplementedwithpiecedcoveragefroma
varietyofstaff.so,Iguessitwouldbemorelikegreaterthan
90%ofthetimeweareincompliance.Butisisveryrarethat
wearenot.
yes wemaintainstaffingratiosatalltimesacrossallsettings
yes
no yes
no yes yes yes forin‐patientunits
no yes
IhaveseveralconcernsontheCAHside:
*wearefrequentlytightonstafftobeginwithahuge,
consistentturnoverofnewgrads;
*ManyCAHsaresoruralitisardtogetregistrystaffonthe
spurofthemoment,ifatall;
*atthehospitalIpreviouslyworkd,weoncehada1hr20min
timeframebeforewegotanRNforalastminutecalloff..the
statefinedusfortheperiod;
Aretheratiosanallornothingdeal?onceyouarea
coupleminutesoutofcompliance,youareoutofcompliance?
WillCAHsbeheldtothesamesteepfineamounts?
yes
StaffingRatioCompliance
Page 89 of 284
July 25, 2018
TO: CNO Advisory Committee Members
FROM: Peggy Broussard Wheeler, Vice President, Rural Health Care and Governance
SUBJECT: SB 1152 – Homeless Patient Discharge
SUMMARY
This is the link to the latest, amended version of SB 1152, dated June 28,
2018. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201720180SB1152
The amendments to the bill include:
a. To limit the health and mental health information a hospital must provide to social service
agencies to the patient’s known post-hospital health and mental health care needs.
b. To allow a physician or the physician’s designee to communicate post discharge medical needs
to the homeless patient.
c. To clarify that a treating physician is required to provide a medical screening examination and
evaluation, to a homeless patient, as required by current law, rather than a “mental health
status exam.”
d. To delete the requirement, when follow up mental health care is needed, that the homeless
patient be treated or referred to the county behavioral health department or the patient’s
health plan, to instead require the hospital to coordinate a referral by contacting one of the
following, if applicable: the homeless patient’s health plan, the homeless patient’s primary
care provider, if one has been identified, or another appropriate provider, including but not
limited to the Coordinated Entry System.
e. To limit the distance a hospital is required to transport a patient to within a maximum travel
time of 60 minutes or a maximum distance of 60 miles of the hospital.
f. To clarify the scope of the hospital’s written plan for coordinating services and referrals for
homeless patients with the county behavioral health agency, health care and social services
agencies in the region, health care providers, and nonprofit social services providers, as
available, to assist with ensuring appropriate homeless patient discharge.
g. To delete the requirement that hospitals identify a designated liaison at each participating entity
and develop coordination protocols, and instead require the hospital to provide the contact
information for the homeless shelter’s intake coordinator.
Page 90 of 284
SB 1152 – Homeless Patient Discharge
July 25, 2018
Page 2
h. To allow hospitals to maintain evidence of completion of the homeless patient discharge
protocol in the log or in the patient’s medical record; and to delete the requirement that the log
is updated whenever a homeless patient is discharged.
i. To delete the requirement that patient data submitted to OSHPD include the housing status of
each patient, and whether they were discharged to a social services agency, nonprofit social
services provider, or governmental social services provider.
j. To conform the definition of “homeless patient” to existing law.
k. To delay implementation of the requirement for a written plan for coordinating services and
referrals, including establishing training protocols for discharge planning staff, and the
requirement to maintain a homeless patient discharge log until July 1, 2019.
We remain Oppose, Unless Amended and final amendments are being discussed, with no assurances of
acceptance. The proposed amendments:
Address a new issue related to written consent from patient’s in the discharge policies as
outlined in Section 1262.5. We propose adding clarifying language so written consent is not
required.
Remove the term ‘referred’, if follow up mental health care is needed, and replaces it with
“given written information about” an appropriate follow up provider.
Reduce the 60 minutes, 60 mile maximum requirement when transportation is offered to 15
miles, 30 minutes.
The bill will be heard next in Assembly Appropriations and then the Assembly Floor in August.
DISCUSSION
1. What issues are you facing with your homeless populations?
2. How will the amendments above affect your discharges?
3. Does anyone have a best practice?
ACTION REQUESTED
Committee discussion
Attachment: SB 1152
BJB:br
Page 91 of 284
AMENDED IN ASSEMBLY JUNE 28, 2018
AMENDED IN SENATE MAY 24, 2018
AMENDED IN SENATE APRIL 9, 2018
SENATE BILL No. 1152
Introduced by Senator Hernandez
(Coauthor: Senator Mitchell)
(Coauthor: Assembly Member Gloria)
February 14, 2018
An act to add Section 1262.3 to amend, repeal, and add Section
1262.5 of the Health and Safety Code, relating to public health.
legislative counsel’s digest
SB 1152, as amended, Hernandez. Hospital patient discharge process:
homeless patients.
(1) Existing law requires the State Department of Public Health to
license and regulate general acute care hospitals, acute psychiatric
hospitals, and special hospitals. Existing law requires these hospitals
to comply with specific statutory provisions for standards of care and
regulations promulgated by the department, and a violation of these
provisions or regulations is a crime. Existing law requires each hospital
to have a written discharge planning policy and process that requires
that the appropriate arrangements for posthospital care are made prior
to discharge for those patients likely to suffer adverse health
consequences upon discharge if there is no adequate discharge planning.
This bill would require each hospital to include a written homeless
patient discharge planning policy and process within the hospital
discharge policy, a written homeless patient discharge planning policy
and process that includes, among other requirements, coordinating
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services and referrals for homeless patients, and procedures for homeless
patient discharge referrals to shelters, medical care, and behavioral
health care. The bill would also require each hospital to report specific
information about all patient housing and discharges to the Office of
Statewide Health Planning and Development. policy, as specified. The
bill would require a hospital to document specified information before
discharging a homeless patient. The bill would, commencing on July
1, 2019, require a hospital to develop a written plan for coordinating
services and referrals for homeless patients with the county behavioral
health agency, health care and social service agencies in the region,
health care providers, and nonprofit social service providers, as
available, to assist with ensuring appropriate homeless patient
discharge. The bill would also, commencing on July 1, 2019, require
a hospital to maintain a log of homeless patients discharged and the
locations to which they were discharged. The bill would specify how
its provisions are to be construed in relation to local ordinances, codes,
regulations, or orders related to the homeless patient discharge processes.
Because a violation of these requirements would be a crime, this bill
would impose a state-mandated local program.
(2) The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the state.
Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act
for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
The people of the State of California do enact as follows:
line 1 SECTION 1. Section 1262.5 of the Health and Safety Code is
line 2 amended to read:
line 3 1262.5. (a) Each hospital shall have a written discharge
line 4 planning policy and process.
line 5 (b) The policy required by subdivision (a) shall require that
line 6 appropriate arrangements for posthospital care, including, but not
line 7 limited to, care at home, in a skilled nursing or intermediate care
line 8 facility, or from a hospice, are made prior to discharge for those
line 9 patients who are likely to suffer adverse health consequences upon
line 10 discharge if there is no adequate discharge planning. If the hospital
line 11 determines that the patient and family members or interested
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line 1 persons need to be counseled to prepare them for posthospital care,
line 2 the hospital shall provide for that counseling.
line 3 (c) As part of the discharge planning process, the hospital shall
line 4 provide each patient who has been admitted to the hospital as an
line 5 inpatient with an opportunity to identify one family caregiver who
line 6 may assist in posthospital care, and shall record this information
line 7 in the patient’s medical chart.
line 8 (1) In the event that the patient is unconscious or otherwise
line 9 incapacitated upon admittance to the hospital, the hospital shall
line 10 provide the patient or patient’s legal guardian with an opportunity
line 11 to designate a caregiver within a specified time period, at the
line 12 discretion of the attending physician, following the patient’s
line 13 recovery of consciousness or capacity. The hospital shall promptly
line 14 document the attempt in the patient’s medical record.
line 15 (2) In the event that the patient or legal guardian declines to
line 16 designate a caregiver pursuant to this section, the hospital shall
line 17 promptly document this declination in the patient’s medical record,
line 18 when appropriate.
line 19 (d) The policy required by subdivision (a) shall require that the
line 20 patient’s designated family caregiver be notified of the patient’s
line 21 discharge or transfer to another facility as soon as possible and, in
line 22 any event, upon issuance of a discharge order by the patient’s
line 23 attending physician. If the hospital is unable to contact the
line 24 designated caregiver, the lack of contact shall not interfere with,
line 25 delay, or otherwise affect the medical care provided to the patient
line 26 or an appropriate discharge of the patient. The hospital shall
line 27 promptly document the attempted notification in the patient’s
line 28 medical record.
line 29 (e) The process required by subdivision (a) shall require that
line 30 the patient and family caregiver be informed of the continuing
line 31 health care requirements following discharge from the hospital.
line 32 The right to information regarding continuing health care
line 33 requirements following discharge shall also apply to the person
line 34 who has legal responsibility to make decisions regarding medical
line 35 care on behalf of the patient, if the patient is unable to make those
line 36 decisions for himself or herself. The hospital shall provide an
line 37 opportunity for the patient and his or her designated family
line 38 caregiver to engage in the discharge planning process, which shall
line 39 include providing information and, when appropriate, instruction
line 40 regarding the posthospital care needs of the patient. This
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line 1 information shall include, but is not limited to, education and
line 2 counseling about the patient’s medications, including dosing and
line 3 proper use of medication delivery devices, when applicable. The
line 4 information shall be provided in a culturally competent manner
line 5 and in a language that is comprehensible to the patient and
line 6 caregiver, consistent with the requirements of state and federal
line 7 law, and shall include an opportunity for the caregiver to ask
line 8 questions about the posthospital care needs of the patient.
line 9 (f) (1) A transfer summary shall accompany the patient upon
line 10 transfer to a skilled nursing or intermediate care facility or to the
line 11 distinct part-skilled nursing or intermediate care service unit of
line 12 the hospital. The transfer summary shall include essential
line 13 information relative to the patient’s diagnosis, hospital course,
line 14 pain treatment and management, medications, treatments, dietary
line 15 requirement, rehabilitation potential, known allergies, and treatment
line 16 plan, and shall be signed by the physician.
line 17 (2) A copy of the transfer summary shall be given to the patient
line 18 and the patient’s legal representative, if any, prior to transfer to a
line 19 skilled nursing or intermediate care facility.
line 20 (g) A hospital shall establish and implement a written policy to
line 21 ensure that each patient receives, at the time of discharge,
line 22 information regarding each medication dispensed, pursuant to
line 23 Section 4074 of the Business and Professions Code.
line 24 (h) A hospital shall provide every patient anticipated to be in
line 25 need of long-term care at the time of discharge with contact
line 26 information for at least one public or nonprofit agency or
line 27 organization dedicated to providing information or referral services
line 28 relating to community-based long-term care options in the patient’s
line 29 county of residence and appropriate to the needs and characteristics
line 30 of the patient. At a minimum, this information shall include contact
line 31 information for the area agency on aging serving the patient’s
line 32 county of residence, local independent living centers, or other
line 33 information appropriate to the needs and characteristics of the
line 34 patient.
line 35 (i) A contract between a general acute care hospital and a health
line 36 care service plan that is issued, amended, renewed, or delivered
line 37 on or after January 1, 2002, shall not contain a provision that
line 38 prohibits or restricts any health care facility’s compliance with the
line 39 requirements of this section.
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line 1 (j) Discharge planning policies adopted by a hospital in
line 2 accordance with this section shall ensure that planning is
line 3 appropriate to the condition of the patient being discharged from
line 4 the hospital and to the discharge destination and meets the needs
line 5 and acuity of patients.
line 6 (k) This section does not require a hospital to do either of the
line 7 following:
line 8 (1) Adopt a policy that would delay discharge or transfer of a
line 9 patient.
line 10 (2) Disclose information if the patient has not provided consent
line 11 that meets the standards required by state and federal laws
line 12 governing the privacy and security of protected health information.
line 13 (l) This section does not supersede or modify any privacy and
line 14 information security requirements and protections in federal and
line 15 state law regarding protected health information or personally
line 16 identifiable information, including, but not limited to, the federal
line 17 Health Insurance Portability and Accountability Act of 1996 (42
line 18 U.S.C. Sec. 300gg).
line 19 (m) For the purposes of this section, “family caregiver” means
line 20 a relative, friend, or neighbor who provides assistance related to
line 21 an underlying physical or mental disability but who is unpaid for
line 22 those services.
line 23 (n) (1) Each hospital, as defined in subdivisions (a), (b), and
line 24 (f) of Section 1250, shall include within its hospital discharge
line 25 policy a written homeless patient discharge planning policy and
line 26 process.
line 27 (2) The policy shall require a hospital to inquire about a
line 28 patient’s housing status during the discharge planning process.
line 29 Housing status may not be used to discriminate against a patient
line 30 or prevent medically necessary care or hospital admission.
line 31 (3) The policy shall require an individual discharge plan for a
line 32 homeless patient that helps prepare the homeless patient for return
line 33 to the community by connecting him or her with available
line 34 community resources, treatment, shelter, and other supportive
line 35 services. The discharge planning shall be guided by the best
line 36 interests of the homeless patient, his or her physical and mental
line 37 condition, and the homeless patient’s preferences for placement.
line 38 The homeless patient shall be informed of available placement
line 39 options.
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line 1 (4) Unless the homeless patient is being transferred to another
line 2 licensed health facility, the policy shall require the hospital to
line 3 offer to discharge the homeless patient to a location as follows,
line 4 with priority given to placing the homeless patient at a sheltered
line 5 location with supportive services:
line 6 (A) To a social services agency, nonprofit social services
line 7 provider, or governmental service provider that has agreed to
line 8 accept the homeless patient, if he or she has agreed to the
line 9 placement. The hospital shall provide potential receiving agencies
line 10 or providers written or electronic information about the homeless
line 11 patient’s known posthospital health and mental health care needs
line 12 and shall document the name of the person at the agency or
line 13 provider who agreed to accept the homeless patient.
line 14 (B) To the homeless patient’s residence. In the case of a
line 15 homeless patient, “residence” for the purposes of this
line 16 subparagraph means the location identified to the hospital by the
line 17 homeless patient as his or her principal dwelling place.
line 18 (C) To an alternative destination, as indicated by the homeless
line 19 patient. The hospital shall document the destination indicated by
line 20 the homeless patient or his or her representative.
line 21 (5) The policy shall require that information regarding
line 22 discharge or transfer be provided to the homeless patient in a
line 23 culturally competent manner and in a language that is understood
line 24 by the homeless patient.
line 25 (o) The hospital shall document all of the following prior to
line 26 discharging a homeless patient:
line 27 (1) The treating physician has determined the homeless patient’s
line 28 clinical stability for discharge, and the physician or designee has
line 29 communicated postdischarge medical needs to the homeless
line 30 patient.
line 31 (2) The homeless patient has been offered a meal prior to
line 32 discharge, unless medically indicated otherwise.
line 33 (3) If the homeless patient’s clothing is inadequate, the hospital
line 34 shall offer the homeless patient weather-appropriate clothing.
line 35 (4) The homeless patient has been referred to a source of
line 36 followup care, if medically necessary.
line 37 (5) The homeless patient has been provided with a prescription,
line 38 if needed, and, for a hospital with an onsite pharmacy licensed
line 39 and staffed to dispense outpatient medication, an appropriate
line 40 supply of all necessary medication.
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line 1 (6) The homeless patient has been offered or referred to
line 2 screening for infectious disease common to the region, as
line 3 determined by the local health department.
line 4 (7) The homeless patient has been offered vaccinations
line 5 appropriate to the homeless patient’s presenting medical condition.
line 6 (8) The homeless patient is alert and oriented to person, place,
line 7 and time, or the treating physician has provided a medical
line 8 screening examination and evaluation. If the treating physician
line 9 determines that the results of the medical screening examination
line 10 and evaluation indicate that followup mental health care is needed,
line 11 the homeless patient shall be treated or referred to an appropriate
line 12 provider. The hospital shall coordinate a referral by contacting
line 13 one of the following, if applicable:
line 14 (A) The homeless patient’s health plan, if the homeless patient
line 15 is enrolled in a health plan.
line 16 (B) The homeless patient’s primary care provider, if the patient
line 17 has identified one.
line 18 (C) Another appropriate provider, including, but not limited to,
line 19 the coordinated entry system.
line 20 (9) The homeless patient has been screened for, and provided
line 21 assistance to enroll in, any affordable health insurance coverage
line 22 for which he or she is eligible.
line 23 (10) The hospital has offered the homeless patient transportation
line 24 to the discharge destination identified in paragraph (4) of
line 25 subdivision (n), if that destination is within a maximum travel time
line 26 of 60 minutes or a maximum travel distance of 60 miles of the
line 27 hospital. This requirement shall not be construed to prevent a
line 28 hospital from offering transportation to a more distant destination.
line 29 (p) This section shall remain in effect only until July 1, 2019,
line 30 and as of that date is repealed.
line 31 SEC. 2. Section 1262.5 is added to the Health and Safety Code,
line 32 to read:
line 33 1262.5. (a) Each hospital shall have a written discharge
line 34 planning policy and process.
line 35 (b) The policy required by subdivision (a) shall require that
line 36 appropriate arrangements for posthospital care, including, but
line 37 not limited to, care at home, in a skilled nursing or intermediate
line 38 care facility, or from a hospice, are made prior to discharge for
line 39 those patients who are likely to suffer adverse health consequences
line 40 upon discharge if there is no adequate discharge planning. If the
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line 1 hospital determines that the patient and family members or
line 2 interested persons need to be counseled to prepare them for
line 3 posthospital care, the hospital shall provide for that counseling.
line 4 (c) As part of the discharge planning process, the hospital shall
line 5 provide each patient who has been admitted to the hospital as an
line 6 inpatient with an opportunity to identify one family caregiver who
line 7 may assist in posthospital care, and shall record this information
line 8 in the patient’s medical chart.
line 9 (1) In the event that the patient is unconscious or otherwise
line 10 incapacitated upon admittance to the hospital, the hospital shall
line 11 provide the patient or patient’s legal guardian with an opportunity
line 12 to designate a caregiver within a specified time period, at the
line 13 discretion of the attending physician, following the patient’s
line 14 recovery of consciousness or capacity. The hospital shall promptly
line 15 document the attempt in the patient’s medical record.
line 16 (2) In the event that the patient or legal guardian declines to
line 17 designate a caregiver pursuant to this section, the hospital shall
line 18 promptly document this declination in the patient’s medical record,
line 19 when appropriate.
line 20 (d) The policy required by subdivision (a) shall require that the
line 21 patient’s designated family caregiver be notified of the patient’s
line 22 discharge or transfer to another facility as soon as possible and,
line 23 in any event, upon issuance of a discharge order by the patient’s
line 24 attending physician. If the hospital is unable to contact the
line 25 designated caregiver, the lack of contact shall not interfere with,
line 26 delay, or otherwise affect the medical care provided to the patient
line 27 or an appropriate discharge of the patient. The hospital shall
line 28 promptly document the attempted notification in the patient’s
line 29 medical record.
line 30 (e) The process required by subdivision (a) shall require that
line 31 the patient and family caregiver be informed of the continuing
line 32 health care requirements following discharge from the hospital.
line 33 The right to information regarding continuing health care
line 34 requirements following discharge shall also apply to the person
line 35 who has legal responsibility to make decisions regarding medical
line 36 care on behalf of the patient, if the patient is unable to make those
line 37 decisions for himself or herself. The hospital shall provide an
line 38 opportunity for the patient and his or her designated family
line 39 caregiver to engage in the discharge planning process, which shall
line 40 include providing information and, when appropriate, instruction
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line 1 regarding the posthospital care needs of the patient. This
line 2 information shall include, but is not limited to, education and
line 3 counseling about the patient’s medications, including dosing and
line 4 proper use of medication delivery devices, when applicable. The
line 5 information shall be provided in a culturally competent manner
line 6 and in a language that is comprehensible to the patient and
line 7 caregiver, consistent with the requirements of state and federal
line 8 law, and shall include an opportunity for the caregiver to ask
line 9 questions about the posthospital care needs of the patient.
line 10 (f) (1) A transfer summary shall accompany the patient upon
line 11 transfer to a skilled nursing or intermediate care facility or to the
line 12 distinct part-skilled nursing or intermediate care service unit of
line 13 the hospital. The transfer summary shall include essential
line 14 information relative to the patient’s diagnosis, hospital course,
line 15 pain treatment and management, medications, treatments, dietary
line 16 requirement, rehabilitation potential, known allergies, and
line 17 treatment plan, and shall be signed by the physician.
line 18 (2) A copy of the transfer summary shall be given to the patient
line 19 and the patient’s legal representative, if any, prior to transfer to
line 20 a skilled nursing or intermediate care facility.
line 21 (g) A hospital shall establish and implement a written policy to
line 22 ensure that each patient receives, at the time of discharge,
line 23 information regarding each medication dispensed, pursuant to
line 24 Section 4074 of the Business and Professions Code.
line 25 (h) A hospital shall provide every patient anticipated to be in
line 26 need of long-term care at the time of discharge with contact
line 27 information for at least one public or nonprofit agency or
line 28 organization dedicated to providing information or referral
line 29 services relating to community-based long-term care options in
line 30 the patient’s county of residence and appropriate to the needs and
line 31 characteristics of the patient. At a minimum, this information shall
line 32 include contact information for the area agency on aging serving
line 33 the patient’s county of residence, local independent living centers,
line 34 or other information appropriate to the needs and characteristics
line 35 of the patient.
line 36 (i) A contract between a general acute care hospital and a health
line 37 care service plan that is issued, amended, renewed, or delivered
line 38 on or after January 1, 2002, shall not contain a provision that
line 39 prohibits or restricts any health care facility’s compliance with
line 40 the requirements of this section.
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line 1 (j) Discharge planning policies adopted by a hospital in
line 2 accordance with this section shall ensure that planning is
line 3 appropriate to the condition of the patient being discharged from
line 4 the hospital and to the discharge destination and meets the needs
line 5 and acuity of patients.
line 6 (k) This section does not require a hospital to do either of the
line 7 following:
line 8 (1) Adopt a policy that would delay discharge or transfer of a
line 9 patient.
line 10 (2) Disclose information if the patient has not provided consent
line 11 that meets the standards required by state and federal laws
line 12 governing the privacy and security of protected health information.
line 13 (l) This section does not supersede or modify any privacy and
line 14 information security requirements and protections in federal and
line 15 state law regarding protected health information or personally
line 16 identifiable information, including, but not limited to, the federal
line 17 Health Insurance Portability and Accountability Act of 1996 (42
line 18 U.S.C. Sec. 300gg).
line 19 (m) For the purposes of this section, “family caregiver” means
line 20 a relative, friend, or neighbor who provides assistance related to
line 21 an underlying physical or mental disability but who is unpaid for
line 22 those services.
line 23 (n) (1) Each hospital, as defined in subdivisions (a), (b), and
line 24 (f) of Section 1250, shall include within its hospital discharge
line 25 policy a written homeless patient discharge planning policy and
line 26 process.
line 27 (2) The policy shall require a hospital to inquire about a
line 28 patient’s housing status during the discharge planning process.
line 29 Housing status may not be used to discriminate against a patient
line 30 or prevent medically necessary care or hospital admission.
line 31 (3) The policy shall require an individual discharge plan for a
line 32 homeless patient that helps prepare the homeless patient for return
line 33 to the community by connecting him or her with available
line 34 community resources, treatment, shelter, and other supportive
line 35 services. The discharge planning shall be guided by the best
line 36 interests of the homeless patient, his or her physical and mental
line 37 condition, and the homeless patient’s preferences for placement.
line 38 The homeless patient shall be informed of available placement
line 39 options.
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line 1 (4) Unless the homeless patient is being transferred to another
line 2 licensed health facility, the policy shall require the hospital to
line 3 offer to discharge the homeless patient to a location as follows,
line 4 with priority given to placing the homeless patient at a sheltered
line 5 location with supportive services:
line 6 (A) To a social services agency, nonprofit social services
line 7 provider, or governmental service provider that has agreed to
line 8 accept the homeless patient, if he or she has agreed to the
line 9 placement. The hospital shall provide potential receiving agencies
line 10 or providers written or electronic information about the homeless
line 11 patient’s known posthospital health and mental health care needs
line 12 and shall document the name of the person at the agency or
line 13 provider who agreed to accept the homeless patient.
line 14 (B) To the homeless patient’s residence. In the case of a
line 15 homeless patient, “residence” for the purposes of this
line 16 subparagraph means the location identified to the hospital by the
line 17 homeless patient as his or her principal dwelling place.
line 18 (C) To an alternative destination, as indicated by the homeless
line 19 patient. The hospital shall document the destination indicated by
line 20 the homeless patient or his or her representative.
line 21 (5) The policy shall require that information regarding
line 22 discharge or transfer be provided to the homeless patient in a
line 23 culturally competent manner and in a language that is understood
line 24 by the homeless patient.
line 25 (o) The hospital shall document all of the following prior to
line 26 discharging a homeless patient:
line 27 (1) The treating physician has determined the homeless patient’s
line 28 clinical stability for discharge, and the physician or designee has
line 29 communicated postdischarge medical needs to the homeless
line 30 patient.
line 31 (2) The homeless patient has been offered a meal prior to
line 32 discharge, unless medically indicated otherwise.
line 33 (3) If the homeless patient’s clothing is inadequate, the hospital
line 34 shall offer the homeless patient weather-appropriate clothing.
line 35 (4) The homeless patient has been referred to a source of
line 36 followup care, if medically necessary.
line 37 (5) The homeless patient has been provided with a prescription,
line 38 if needed, and, for a hospital with an onsite pharmacy licensed
line 39 and staffed to dispense outpatient medication, an appropriate
line 40 supply of all necessary medication.
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line 1 (6) The homeless patient has been offered or referred to
line 2 screening for infectious disease common to the region, as
line 3 determined by the local health department.
line 4 (7) The homeless patient has been offered vaccinations
line 5 appropriate to the homeless patient’s presenting medical condition.
line 6 (8) The homeless patient is alert and oriented to person, place,
line 7 and time, or the treating physician has provided a medical
line 8 screening examination and evaluation. If the treating physician
line 9 determines that the results of the medical screening examination
line 10 and evaluation indicate that followup mental health care is needed,
line 11 the homeless patient shall be treated or referred to an appropriate
line 12 provider. The hospital shall coordinate a referral by contacting
line 13 one of the following, if applicable:
line 14 (A) The homeless patient’s health plan, if the homeless patient
line 15 is enrolled in a health plan.
line 16 (B) The homeless patient’s primary care provider, if the patient
line 17 has identified one.
line 18 (C) Another appropriate provider, including, but not limited to,
line 19 the coordinated entry system.
line 20 (9) The homeless patient has been screened for, and provided
line 21 assistance to enroll in, any affordable health insurance coverage
line 22 for which he or she is eligible.
line 23 (10) The hospital has offered the homeless patient transportation
line 24 to the discharge destination identified in paragraph (4) of
line 25 subdivision (n), if that destination is within a maximum travel time
line 26 of 60 minutes or a maximum travel distance of 60 miles of the
line 27 hospital. This requirement shall not be construed to prevent a
line 28 hospital from offering transportation to a more distant destination.
line 29 (p) A hospital shall develop a written plan for coordinating
line 30 services and referrals for homeless patients with the county
line 31 behavioral health agency, health care and social services agencies
line 32 in the region, health care providers, and nonprofit social services
line 33 providers, as available, to assist with ensuring appropriate
line 34 homeless patient discharge. The plan shall be updated annually
line 35 and shall include all of the following:
line 36 (1) A list of local homeless shelters, including their hours of
line 37 operation, admission procedures and requirements, client
line 38 population served, and general scope of medical and behavioral
line 39 health services available.
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line 1 (2) The hospital’s procedures for homeless patient discharge
line 2 referrals to shelter, medical care, and behavioral health care.
line 3 (3) The contact information for the homeless shelter’s intake
line 4 coordinator.
line 5 (4) Training protocols for discharge planning staff.
line 6 (q) Each hospital shall maintain a log of homeless patients
line 7 discharged and the locations to which they were discharged. The
line 8 hospital shall maintain evidence of completion of the homeless
line 9 patient discharge protocol in the log or in the patient’s medical
line 10 record.
line 11 (r) For purposes of this section, “homeless patient” has the
line 12 same meaning as provided in Section 1262.4.
line 13 (s) It is the intent of the Legislature that nothing in this section
line 14 shall be construed to preempt, limit, prohibit, or otherwise affect,
line 15 the adoption, implementation, or enforcement of local ordinances,
line 16 codes, regulations, or orders related to the homeless patient
line 17 discharge processes, except to the extent that any such provision
line 18 of law is inconsistent with the provisions of this section, and then
line 19 only to the extent of the inconsistency. A local ordinance, code,
line 20 regulation, or order is not deemed inconsistent with this section
line 21 if it affords greater protection to homeless patients than the
line 22 requirements set forth in this section. Where local ordinances,
line 23 codes, regulations, or orders duplicate or supplement this section,
line 24 this section shall be construed as providing alternative remedies
line 25 and shall not be construed to preempt the field.
line 26 (t) Nothing in this section alters the health and social service
line 27 obligations described in Section 17000 of the Welfare and
line 28 Institutions Code.
line 29 (u) This section shall become operative on July 1, 2019.
line 30 SECTION 1. Section 1262.3 is added to the Health and Safety
line 31 Code, to read:
line 32 1262.3. (a) (1) Each hospital, as defined in subdivisions (a),
line 33 (b), and (f) of Section 1250, shall include within its hospital
line 34 discharge policy established pursuant to Section 1262.5 a written
line 35 homeless patient discharge planning policy and process.
line 36 (2) The policy shall require a hospital to inquire about a patient’s
line 37 housing status during the discharge planning process. Housing
line 38 status may not be used to discriminate against a patient or prevent
line 39 medically necessary care or hospital admission.
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line 1 (3) The policy shall require an individual discharge plan for a
line 2 homeless patient that helps prepare the homeless patient for return
line 3 to the community by connecting him or her with available
line 4 community resources, treatment, shelter, and other supportive
line 5 services. The discharge planning shall be primarily guided by the
line 6 best interests of the homeless patient and his or her physical and
line 7 mental condition, taking into consideration the homeless patient’s
line 8 preferences for placement. The homeless patient shall be informed
line 9 of available placement options.
line 10 (4) Unless the homeless patient is being transferred to another
line 11 licensed health facility, the policy shall require the hospital to offer
line 12 to discharge the homeless patient to a location as follows, with
line 13 priority given to placing the homeless patient at a sheltered location
line 14 with supportive services:
line 15 (A) To a social services agency, nonprofit social services
line 16 provider, or governmental service provider that has agreed to accept
line 17 the homeless patient, if he or she has agreed to the placement. The
line 18 hospital shall provide potential receiving agencies or providers
line 19 written or electronic information about the homeless patient’s
line 20 health and mental health care needs and shall document the name
line 21 of the person at the agency or provider who agreed to accept the
line 22 homeless patient.
line 23 (B) To the homeless patient’s residence. In the case of a
line 24 homeless patient, “residence” for the purposes of this subparagraph
line 25 means the location identified to the hospital by the homeless patient
line 26 as his or her principal dwelling place.
line 27 (C) To an alternative destination, as indicated by the homeless
line 28 patient or the homeless patient’s representative. The hospital shall
line 29 document the destination indicated by the homeless patient or his
line 30 or her representative.
line 31 (5) The policy shall require that information regarding discharge
line 32 or transfer be provided to the homeless patient in a culturally
line 33 competent manner and in a language that is understood by the
line 34 homeless patient.
line 35 (b) The hospital shall document all of the following prior to
line 36 discharging a homeless patient:
line 37 (1) The treating physician has determined the homeless patient’s
line 38 clinical stability for discharge, and communicated postdischarge
line 39 medical needs to the homeless patient.
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line 1 (2) The homeless patient has been offered a meal prior to
line 2 discharge, unless medically indicated otherwise.
line 3 (3) If the homeless patient’s clothing is inadequate, the hospital
line 4 shall offer the homeless patient weather-appropriate clothing.
line 5 (4) The homeless patient has been referred to a source of
line 6 followup care, if medically necessary.
line 7 (5) The homeless patient has been provided with a prescription,
line 8 if needed, and, for a hospital with an onsite pharmacy licensed and
line 9 staffed to dispense outpatient medication, an appropriate supply
line 10 of all necessary medication.
line 11 (6) The homeless patient has been offered or referred to
line 12 screening for infectious disease common to the region, as
line 13 determined by the local health department.
line 14 (7) The homeless patient has been offered vaccinations
line 15 appropriate to the homeless patient’s presenting medical condition.
line 16 (8) The homeless patient is alert and oriented to person, place,
line 17 and time, or the treating physician has provided, or attempted to
line 18 provide, a mental health status exam. If the treating physician
line 19 determines that the results of the mental health status exam indicate
line 20 that followup mental health care is needed, the homeless patient
line 21 shall be treated or referred to an appropriate provider, including,
line 22 but not limited to, the county behavioral health department or the
line 23 homeless patient’s health plan, if the homeless patient is enrolled
line 24 in a health plan. The hospital shall coordinate a referral by
line 25 contacting the provider or health plan that the homeless patient is
line 26 being referred to and providing the name and contact information
line 27 of the homeless patient, if available.
line 28 (9) The homeless patient has been screened for, and provided
line 29 assistance to enroll in, any affordable health insurance coverage
line 30 for which he or she is eligible.
line 31 (10) The hospital has provided the homeless patient with
line 32 transportation to the discharge destination identified in paragraph
line 33 (4) of subdivision (a).
line 34 (c) A hospital shall develop a written plan for coordinating
line 35 services and referrals for homeless patients with the county
line 36 behavioral health agency, health care and social services agencies
line 37 in the region, health care providers, and nonprofit social services
line 38 providers to assist with ensuring appropriate homeless patient
line 39 discharge. The plan shall be updated annually and shall include
line 40 all of the following:
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line 1 (1) A list of local homeless shelters, including their hours of
line 2 operation, admission procedures and requirements, client
line 3 population served, and scope of medical and behavioral health
line 4 services available.
line 5 (2) Procedures for homeless patient discharge referrals to shelter,
line 6 medical care, and behavioral health care.
line 7 (3) Designated liaisons at each participating entity.
line 8 (4) Coordination protocols with participating entities.
line 9 (5) Training protocols for discharge planning staff.
line 10 (d) Each hospital shall maintain a log of homeless patients
line 11 discharged, the locations to which they were discharged, and
line 12 evidence of completion of the homeless patient discharge protocol.
line 13 The log shall be updated whenever a homeless patient is
line 14 discharged.
line 15 (e) Each hospital shall include in the patient data submitted to
line 16 the Office of Statewide Health Planning and Development the
line 17 housing status of each patient, classified as permanently housed,
line 18 temporarily housed, or unhoused, and his or her disposition,
line 19 including, but not limited to, whether he or she was discharged to
line 20 a social services agency, nonprofit social services provider, or
line 21 governmental social services provider.
line 22 (f) For purposes of this section, “homeless patient” means a
line 23 patient who lacks a fixed and regular nighttime residence, who
line 24 has a primary nighttime residence that is a supervised publicly or
line 25 privately operated shelter designed to provide temporary living
line 26 accommodations, or who is residing in a public or private place
line 27 that is designed either to provide temporary living accommodations
line 28 or to be used as a sleeping accommodation for human beings.
line 29 (g) It is the intent of the Legislature that nothing in this section
line 30 shall be construed to preempt, limit, prohibit, or otherwise affect,
line 31 the adoption, implementation, or enforcement of local ordinances,
line 32 codes, regulations, or orders related to the homeless patient
line 33 discharge processes, except to the extent that any such provision
line 34 of law is inconsistent with the provisions of this section, and then
line 35 only to the extent of the inconsistency. A local ordinance, code,
line 36 regulation, or order is not deemed inconsistent with this section if
line 37 it affords greater protection to homeless patients than the
line 38 requirements set forth in this section. Where local ordinances,
line 39 codes, regulations, or orders duplicate or supplement this section,
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line 1 this section shall be construed as providing alternative remedies
line 2 and shall not be construed to preempt the field.
line 3 SEC. 2.
line 4 SEC. 3. No reimbursement is required by this act pursuant to
line 5 Section 6 of Article XIIIB of the California Constitution because
line 6 the only costs that may be incurred by a local agency or school
line 7 district will be incurred because this act creates a new crime or
line 8 infraction, eliminates a crime or infraction, or changes the penalty
line 9 for a crime or infraction, within the meaning of Section 17556 of
line 10 the Government Code, or changes the definition of a crime within
line 11 the meaning of Section 6 of Article XIIIB of the California
line 12 Constitution.
O
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July 25, 2018
TO: CNO Advisory Committee Members
FROM: BJ Bartleson, MS, RN, NEA-BC, Vice President, Nursing and Clinical Services
SUBJECT: CNO Survey Questionnaire
SUMMARY
Per request of committee members, a survey was sent to CNO Committee members to understand
priorities within their organization in general, as viewed by their CEO/Board, and as identified by the
CNO. Results are attached.
DISCUSSION
1. After reviewing the grid, are there areas that stand out?
2. Is there overlap, and if so where?
3. What next steps does the group propose?
ACTION REQUESTED
Committee to decide next steps
Attachment: Meeting Priorities spreadsheet
Top Insights from the 2017 System Chief Nurse Executive Roundtable
BJB:br
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4-25-18 CNO Advisory Committee Priorities 4/23/2018
1 2 3 1 2 3 1 2 3
Pending integration
with CHI
EHR optimization
cost efficiency /
reduction
pending integration
reduction of costed -
improved EBITA
patient experience /
quality
patient experience /
engagement
employee engagement
nursing leadership
development
Decreasing expenses
Improving quality
outcomes/rankings
capacity/patient
flow/decreasing LOS
Decreasing expenses
Improving quality
outcomes/rankings
capacity/patient
flow/decreasing LOS
Decreasing expenses Improving quality outcomes/rankings
capacity/patient
flow/decreasing LOS
Increasing volume of
covered lives in a risk
model
limited funding and
changes in funding
models for public
hospitals
recruitment and
retention of
experienced specialty
RNs
Volume expansion
through expansion of
our community
footprint
Leadership development at all
levels of the organization and
bedside
flexible work hours and work life balance for staff
RNs
recruitment and
retention of top
talent at the bedside
and at nursing
director levels
Preparing for the future nurse
shortage
Involvement or lack thereof by millennials getting
involved in hospital councils
need for nurses
having a greater voice
at the executive table
Succession
development
CNO
retirement/replacement
needs
strategies around opioid
utilization
Hospitals are pricing themselves
out of the market
Lack of providers
Outsourcing of services to
outpatient centers
construction demands
due to regulatory
mandates
obtaining the services
of a general surgeon
financing construction
costs associated with
continually changing
regulations
maintaining patient
safety and satisfaction
maintaining adequate, quality
staffing
managing employee issues in a time where there is
emphasis on personal interests and aggressive
behaviors
keeping up with a
constant barrage of
new quality-related
regulations, data
collection and
reporting with
minimal staff and an
antiquated EHR
system
The following are in
no particular
bucket:
Mental Health Resources
Homeless / homeless
bill proposal
Proposed bill to lower
commercial payments
to 120% of Medicare
Opioid Use
Increasing financial
pressure, declining
reimbursements and
resources
Merger - changing locus
of control
Physician strategy -
competition, purchase
financial - action Oi
benchmarking,
McKinsey work
quality - decreasing
harm
patient experience /
quality
decreasing harm, safety, quality efficiency / productivity
flow and caregivers
engagement
What are the three issues your organization is facing?
Which issues have been prioritized by your CEO/Board?
What are your top three issues?
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1 2 3 1 2 3 1 2 3
What are the three issues your organization is facing?
Which issues have been prioritized by your CEO/Board?
What are your top three issues?
Financial pressures
We are being
increasingly squeezed
financially. Not only
by the government
payors but also in the
private sector.
Insurance contracts
are not keeping up
with the costs of
providing care. The
increasing costs of
supplies and
medications (which
can go up 600%
within months). The
costs of physicians
keep increasing, now
there are hospitalists,
OB hospitalists, and
on call (insert name of
specialty here)
physicians.
Regulatory changes -
There has been
increasing amounts of
regulations from multiple
agencies. It sometimes
feels like I just have to
decide which regulation
to violate. In the ED
alone, I have staffing
ratios, building fire codes
and EMTALA. During the
peak of the flu season,
ambulance crews said
they were told by the
county EMS to leave the
patients on cots/empty
stretchers within 20
minutes. (Staff hid empty
beds/stretchers, they are
so resourceful)
Contracting –
contracting is becoming
more intense. The plans
are increasingly not
keeping up to the costs
of care. Everyone wants
an increase: supply
vendors, contract
physicians and staff.
Maintain the budget
– hard to do when
you are being asked
to provide more with
less resources. It is a
challenge to keep
supply costs down
(with costs rising),
decrease overtime
(not enough specialty
nurses) and cuts to
support staff and
processes (“live on
Medicare”).
Physician alignment –
there has been a great
deal of conflict
between physicians,
medical groups and
the hospital.
Physicians are
becoming burned out
and whenever
anything is asked of
them it appears to be
“a push from
Administration”.
Instead of new
regulatory
expectation. There
are more people vying
for the same dollar.
Expanding services –
To stay relevant we
have to improve and
expand services. We
just purchased two
new surgical robots.
We are expanding the
ED and adding 4 more
surgical suites.
Staffing – There is a shortage of
experienced nurses in specialty
areas. In our facility, we are
short nurses in ED, ICU, OR and
Home Health. We provide a
great deal of mentoring and
education of new grads (6
months to 1 year). After
finishing training or at 2 years,
the millennials will leave to go
to jobs in union organizations
for more money. These other
organizations do not provide
new grad training but instead
offer substantially more money
since the employee is now an
experienced staff member. We
hear that the ex-employee does
not enjoy their new work
environment but they stay for
the money. Use of overtime or
registry staff is expensive and
breaks the budget.
Behavioral Health patients – Homeless and
Behavioral health patients have become a huge
burden. There are people who use the system to
get a home and financial resources from hospitals.
The Homeless clog the ED when the weather is bad.
I have had people say to our Social Worker when
we have set them up in a motel “What about
money for food? The last hospital gave me money
also.” The BH patients have been increasing and
there is nowhere to send them (especially children).
We actually have a locked adult unit but for those
patients who do not meet 5150 criteria there is no
place that will treat the patient unless they have
insurance. We have had children waiting for
placement for 8-10 days. The county does not have
the resources to provide outpatient care. Plus, the
BH patients increase the violence that staff are
subjected to. Their families, too, are verbally
abusive to staff and physicians. Both of these
populations create patient flow bottlenecks and
severely hamper our ability to care for medical
patients. Our throughput measures are negatively
impacted.
Maintaining Joy in
Management – It is
hard to have stability
when you do not
have stable middle
management. Staff
do not want to work
5 days per week. The
millennials want
“work life balance”. In
nursing, the span of
control to too much. I
am having difficulty
helping us maintain
joy in our work.
Financial pressures
are a burden.
The CDPH Centralized
Application unit
prevented breaking
ground on the ED for six
months. (Domino process)
- We were not able to
move the departments
we were vacating to
remodel into ED space
into their new space
because the new space
was not licensed yet. So
the new space stayed
empty and construction
was delayed.
Short staffed lack of engagement
effective
communication engagement vision of nursing representation engagement vision of nursing representation
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1 2 3 1 2 3 1 2 3
What are the three issues your organization is facing?
Which issues have been prioritized by your CEO/Board?
What are your top three issues?
Payer mix changes
(increased MediCal)
decreased
commercial
Increased union activity
surrounding "at all times"
nursing ratio provision
Improving overall
quality and the high
reliability journey
Quality Patient experience financial performance
Improving the level of
professionalism within nursing
Improving clinical quality
Improving the patient
experience
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7/19/2018
1
TheresaMurphy,RN,MS,CENP
ChiefNursingOfficer
USCVerdugoHillsHospital
GlendaleCA
Purpose
PresentthegrowingconcernoftheimpactofSpanofControlinthe
hospitalsetting
Reviewkeyfindingsintheliteraturerelatedtothistopic
OfferrecommendationsforhowtoapproachSpanofControldecision‐
makingwithemphasisonhospitalnursemanagers
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2
Why - Initial concerns
Observationsoffatigue,burnoutoffrontlineleaders
Staffdisengagementleadingtoincreasedstaffturnover
Qualityoutcomesjeopardizedduetomultiplefactorsincluding:
Increasedcomplexityofpatientconditions
Increasedcomplexityoftechnologyadvancements
Trainingandskillsrequirements
Churnoffrontlinestaff
Multipledemandscompetingforcaregiverattentionincludingdata
collection;reporting,patientexperience,makingendsmeetwith
decreasingfunds
Why?
Hospitalsexperiencingcontinuedstrainonfinancialhealthrelatedtorevenue
flowsandoperationalexpenses
FinancialchallengescitedasoneofthetopconcernsofhospitalCEOs
CostofLaboronethetoplineitemoperatingexpenses
CompeteswithotherhighdollardemandsincludingIT,TechnologyandFacilities
costs
Increaseddemandsforreportingcopiousamountsofdatatovariousagencies
Qualityoutcomeswithfinancialpenalties
Consumerdemandforincreasedqualityleadingtochangesinworkflows
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7/19/2018
3
Changes in past 20 years in healthcare
leading to New Challenges
Workloadchanges
Increasedchurn
DecreasedLOSleadstoworkloadcompression
Increasedpatientacuity/complexity
Livinglonger,heavier,sicker(moreco‐morbidities)
Increasedregulatoryandreportingburden
Socialfactors
Increasedbehavioralhealthdemands,especiallyinEDs
ManyBHpatientswithmedicalco‐morbiditiesinacutemed‐surg unitsthatmay
notbedesignedorhaveallocatedresourcesforaddedsafetyornon‐medical
attentionrequired
Changingdemographicsofincominganddivergentworkforce
Crossgenerationalworkforcewithdiversevalues,supportdemands,work‐life
balancedemands,methodsoflearning
Challengeswithcompensationcompression
DirectcareRNscanmakemorethanmanagers(similarproblemthatuniversities
arefacingwithrecruitingfaculty)
Poorprogressionandtrainingintomanagementduetourgentneedstofilltheneed
=downstreamcosts
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4
ImpactofEHR
Optimizationstillinevolution
Extricating“thestory”stilloftennoteasytoobtain,transparent,orcomplete
Financialstressorswithnewreimbursementmodels
Reimbursementchangeswithincreasedriskmodels
Payor demandchangestowardvalue–costofgettingitwrong
Episodeofcaremodelsplacingaddedriskonhospitals
Underinsuredleadingtounrecognizedcharitycare=undercompensatedservices
UniqueconsiderationsforHealthcare
Uniquetypeofcomplexity–productproducedatthemomentofcreation;opportunityto
adjust,revise,fixmustoccurbeforedelivery
Standardizationlimitationduetoinfinitevarietyofhumanconditions
Natureofservices(healthcare)continuous,complexandcustomized
HighConsequence‐ Errorscanleadtoharm
Professionalautonomyofproviders
Dynamicdeliveryenvironment(paymentstructures;noveldiseases;changingdemands)
Impactoftechnology
Variationofprovidertypeswithinahospital
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5
Workforcedemandfornursesandotherclinicalleadersstrainingsupply
drivingupcostsandstrainingpoolofclinicalleadersinterestedinmanagementpositions
CostsandSupplyfactorsmayinfluenceorganizationalstructuresthatexpand
spansofcontrolascostcontainmentefforts
Evidenceofconsequencesoflargespansofcontrol
Balancing Act
Meetingshrinkingrevenues
Meetingqualitymetrics
Meetingcustomerdemands
Meetingemployeedemands
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6
Two Points of View
- Academic inquiry and HASC NAC
Twostudies:
Academic,graduatestudyfindings
HASCNurseAdvisoryCouncil(NAC)SOCprojectfindings
articulatedinWhitePaperwiththeintentionofdeveloping
actionablerecommendationstohospitalleaders
HASCNACTaskForce:
AnnaOmery JimFinkelstein
AnnDechairo‐Marino KathyHerran
BeverlyQuaye
Terms
SpanofControl‐ ScopeofResponsibility
Personnel;Projects;Space;Budget,Business,Operations
Outcomes:Resultingoutputtowardoperationalobjectives
Toonarrow– wastedtime,talent,expense
Toobroad– jeopardizequality&safety,increasefatigue,dissatisfaction
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7
Literature Review - Thesis
LittleevidencefordeterminationofSOCinhealthcaresettings
Evidenceofhighlyorganizedstructuresinancientsocieties
Limitedevidenceoforganizationalstructuresinmodernsocietyuntil
IndustrialRevolution
HenriFayol,Frenchindustrialist–earlyformalizationofmanagementtheory
5keyresponsibilitiesofamanager(planning,organizing,commanding,coordinating,
controlling)
DanielMcCallum–railroadsuperintendent& GeneralinLincolnAdministration
Creditedwithcreatingtheorganizationalchart
FrederickWinslowTaylor
ScientificManagement–TimeandMotionstudies
HenryFord
Assemblylineprocess;specialization;efficiency
V. A . Graicunas,Frenchmanagementexpert
Compoundingnatureofrelationshipsasnumberofsubordinatesincreases
C=total;N=subordinates
C=N[(2N/2)+N‐1]
2subordinates=6relationships
3=18
10=5,210
Gulick andUrwick
Volume,Complexity,Geographicdispersion
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8
Volume Complexity GeographicDispersion
‐Numberofbeds (6‐12)
‐Numberofpatients
‐Numberofstafftocare
#ofemployeestomanage
‐schedules;timecards;annualandintra‐
annualevaluations;
‐competencyvalidation;
‐performancemanagement;
‐development;recognition
Complexityofrelationshipsto
manage
‐AccountingFTE≠numberof
employees
‐Variousemploymentstatusescan
leadtoamuchlargernumberof
EE
Patientpopulation
Workervariation(novicetoexpert;
dependenttoautonomous)
Stabilityofenvironment
Customersatisfaction
Increasingregulatory&reporting
Increasedchurn
Increaseddensityofunwellness
Increasedpaceoftechnology changes
rapid
EHR
Shrinkingmargins;costcontainment
#andlocationofunits
#ofDirect
Reports
Geographic
Dispersion
Complexity
of
Environment
KeyFactorstoConsider
16
•Relationshipsto
manageincrease
exponentiallywith
eachadditional
directreportadded
•#ofdirectreports:
‐decrease
w/increased
complexityor
dispersion
•Stabilityof
environment
•Expertise/autonomy
ofstaff
•Skilllevelof
manager
•Moredistancebetweenareas
ofresponsibility,fewerareas
tomanage.
•Maybeoffsetbytechnology
toimprovecontact.
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9
24/7natureofinpatientunits
Equivalentto4.1businessunits
Impactoncommunication,reachingallEEwithinformation
Limitationonmanagertoreachallhoursofthedaywhenmuch
ofbusiness/administrativeworkoccursduringbusinesshours
Complexityoftheunit/service
Stabilityofthedepartment
Churn
Teamdynamics– stateofstorming
1.6%turnoverrateper50employees(=8peryear)
At$50k/EE=$400,000inTOcostsalone
Maturityofthestaff
Autonomyofthestaff
Developmentofinternalstructuresandstandardization
1–8hr
department
1– 24/7hr
department
Impactof24/7Operation
18
One8hourbusinessunit=
Three24/5units
One24/7unitx365=4.2
businessunits
Irregularschedules
(FT/PT/PD)and
changingteammembers
=increasedcomplexity
includingchallenging
communication
pathways
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10
Additional Cost Factors to Consider
Non‐ClinicalWork(Projects)
ThemoreprojectsthesmallerSOC
Quality
Instabilitycanleadtoadverseandcostlyqualityoutcomes;LOS;patientexperience
Engagement
DecreasedengagementduetofatiguecanleadtoincreasedLOS,decreasedsafety
reporting,actions,increasedshortcutsandat‐riskbehavioralchoices
ValueofClericalSupport
20
Nursemanagersreport
spending20%‐40%of
timemanagingtimeand
attendance
Nursemanagers report
spending20%‐40%oftime
managingtimeand
attendance
25%+increaseinproductivity
withaddedclerical/admin
support
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11
SmallerSpan ofControl LargerSpanofControl
Higher:
‐Complexity
‐Instability
‐#ofProjects
‐DiversityofWorkerType
‐Geographicdistancebetweenunits
Lower:
‐Managerexperience
‐Managerprofessional
development/personalmaturity
‐Clerical,Admin,EducationSupport
Lower:
‐Complexity
‐Diversity ofWorkerType/Reporting
Structure
‐Geographicdispersionofunits
‐#Projects
Higher:
‐MaturityofLeader and/orStaff
‐Clerical, Admin,EducationalSupport
‐Unitstability
Findings – literature review - NAC
RefertoNACWhitepaperforlistofreferences
LargeSOCassociatedwith
Dissatisfaction
Burnout
Negativelyimpactedqualityofcare
Effectiveness
NoleadershipstylecanovercomeawideSOC
EvenifhighEIcannotempowerstaffiftoolarge(can’tgettoallofthem)
Donotunderestimatethevalueofclerical/administrativesupport
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12
AssignmentbyFTEratioisoutdated
NewModelconsiderations
Attitudeofnewleaders
Integrationoftechnology
Newtoolstoassess
Newcompetenciesrequired
LargeSOCleadstomanagerfeelingsof
Inadequacy
Exhaustion
Failure
What to do with the information?
-NAC Group Approach
Donebedian’s – Structure‐Process‐Outcomesmodel
PROCESS STRUCTURE OUTCOME
-Materialresources
-Humanresources
-Organization
characteristics
-Activities/actions
stemmingfrom
structuresleadingto
outcomes
-Ex:
management/admin
activitiesc/tfrontline
participationin
activities
-Performancemeasures
of
HR
Financial
Quality
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13
Likely Impact of Increased Span of
Control
DRIVER +IMPACT ‐IMPACT MEDIATING
Outcomes 0 5 3
Structures144
Processes 0 2 3
11110
Evidence-Based Conclusion
ThereisnosinglemetricthatdrivesthemostefficaciousSpanof
Controlforanyorganization
Rather,themostappropriate,effectiveandefficientspanofcontrolis
dependentonunderstandinghowone’sorganizationmeasuresagainst
performancemetricsassociatedwithstructuresandprocesses.
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14
Evidence-Based Conclusions
AlwaysgoingtohavecostsassociatedwithalargeSOC
Thequestioniswhatrisktheorganizationwillbear
Costofburnoutleadingtoturnover
Costoferrorsduetofatigueorinsufficienttraining/supervision/support
Costofadverseclinicaloutcomes(LOS,harm,inefficienciesinflow)
Costofdecreasedstaffengagement
Costofdecreasedpatientsatisfaction
Noleadershipstylewillovercomealargenumberofstaffreportingtoasingle
manager
CantoleratelargerSOCwithappropriatetypeandleveloftoolsandtechnology
ValueofClericalsupport
Threats of Inaction
IncreasedCostsduetothreatto/of:
Worksatisfaction
Engagement
Effectiveness
Quality
Stability
Turnover
Commitmenttoorganization
Burnout
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15
Conclusions
SOCisnolongerjustanHRissue
SOCisbiggerthannursingthoughnursinghasthelargestimpactonpatientsand
clinicaloutcomes
Importantstrategic,businessissue
Requiresassessmentandmonitoringofdataandtiedtooutcomesandincentives
SOCneedstobebalanced
withdesiredoutcomesofCost,Quality,PatientSatisfactionandEmployeeEngagement
ModelGoalsandIncentivesaroundthesemetrics
The Ottawa Hospital Span of
Control Decision-Making Tool
3 Categories 8 Indicators
- Unit
-Staff
- Program(s)
- Unit complexity
- Material management
- Staff volume
- Skill/autonomy
- Stability
- Diversity (# of leaders manager
reports to; projects)
- Budgetary
- Statistical
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16
Recommendations – Call to
Action
UseTOHdecision‐makingtool
CrosswalkwithIOMrecommendations
Partnerwithacademiatostudyfurther
Datawill
informus
Driveconversations
ProvideforaSOCformaximumeffectivenessforspecific
environments
Closingthoughtsforcomparison
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17
How do other High Consequence
Industries approach organizational
structure and SOC?
NuclearPowerplant
CommercialAirlines
HighSpeedRail
LawEnforcement
Military–SEALTeam,StrikeForcevsRegiment
FireFighters–highrisestructurefirevresidentialfirevbrushfire
Consequences
Ifwedon’tgetthisright,
theconsequenceswillbeexponential
HASCNACWhitePaper
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18
Thankyou
Page 146 of 284
July 25, 2018
TO: CNO Advisory Committee Members
FROM: Theresa Murphy, RN, MS, CENP, CNO, USC Verdugo Hills Hospital
Teri Hollingsworth, Vice President Association and HR Services, Hospital Association of
Southern California (HASC)
SUBJECT: HASC Span of Control Study
SUMMARY
Over the last several years, the HASC Nursing Leadership Council has worked on research related to
Nursing Span of Control. A HASC Span of Control Subcommittee was formed, conducted research and
completed a white paper. The white paper was done in conjunction with Kaiser and Future Sense. An
article entitled, “Reexamining Nurse Manager Span of Control with a 21st Century Lens” was drafted.
DISCUSSION
1. How did the concept for the study get initiated?
2. What were some lessons learned?
3. What has germinated from the work?
4. What are the take home messages for others to use?
ACTION REQUESTED
Information only
Attachments: Span of Control: Clinical, Business Impacts and Solutions
Span of Control Tool for Clinical Managers
Span of Control
BJB:br
Page 147 of 284
Page 148 of 284
TABLE OF CONTENTS
Impact of Span of Control ........................................................... 3
Mediating Factors ....................................................................... 5
Myths & What Leaders Can Do .................................................. 7
Conclusion ................................................................................ 10
Acknowledgements ................................................................... 11
2 • Span of Control: Clinical, Business Impacts and Solutions
With any questions, please contact Teri Hollingsworth, HASC VP, Human Resources Services at
(213) 538-0763 or thollingsworth@hasc.org.
Page 149 of 284
You close the car door, run up the steps
and wave “Hi” to the security guard. You are
stopped in the hallway three times by RNs
wearily leaving the unit to head home after
a long night shift. Then you open your
computer to nd a pile of new emails. But
things are just warming up — the charge
nurse is waiting outside with what looks like
a checklist of questions long enough to be
a memoir, and in 20 minutes, it’s time for
the CNO to come to the unit for leadership
rounding. Looming in the back of your mind
are the performance reviews for the 78 direct
reports still needing to be done.
This is reality for the rst 10 minutes of an average
day for a nurse manager.
As hospital budgets tighten, the number of nurse
manager positions have been cut, not only increasing
responsibilities for nurse managers, but also signi-
cantly boosting the number of direct reports. This
increase in span of control (SOC) has left nurse
managers reporting feelings of exhaustion, inade-
quacy and failure. Using the last decade’s worth of
research, the Hospital Association of Southern
California, or HASC, aggregated the studies with the
goal of nding empirical data to help hospital leaders
make effective decisions and appropriately manage
the span of control within their organizations.
To this end, this white paper aims to:
IMPACT OF SOC
At the heart of SOC is people — it impacts everyone
within hospital walls. The three groups most impacted
by SOC are the nurse managers themselves, nursing
staff and patients.
NURSE MANAGERS
The rst logical place to explore SOC begins with
nurse managers, as much of the burden (and let us
not forget opportunity) in this industry falls squarely on
their shoulders. The impact of SOC on the nurse man-
ager is not entirely clear, however. In a systematic
review of the literature addressing its effect on nurse
managers, the results all indicate that SOC’s impact
is multifactorial — meaning there is no one correlation
or simple answer. There are two primary areas SOC
impacts nurse managers — competency and capacity.
Competency
When delving into competency, we should start where
it all begins — hiring. Hospitals seem to recruit for that
perfect balance of clinical competency, emotional intel-
ligence and strong leadership skills that make a great
nurse manager. Research reveals that leaders who
have a higher level of knowledge, experience
and self-condence can manage a larger SOC than
nurses with less self-condence. So yes, hiring the
best and brightest nurse managers who are not just
clinically competent, but also great leaders, can help
manage and increase SOC for units. Strong leaders
will perform better and can even tolerate a larger SOC,
but even the best and brightest have limits. As SOC
increases, the impact of a manager’s emotional intel-
ligence decreases. The research shows us that even
leaders with abundant emotional intelligence may not
be able to empower their staff if the SOC is too large.1
Capacity
The adage goes, “even Superman has his kryptonite.”
The same goes for our superheroes in scrubs —
nurse managers. The capacity of nurse managers is
impacted signicantly by SOC both professionally and
personally.
•Provide a practical overview of the research
demonstrating the impact of SOC on people
(nurse managers, staff, and patients)
•Explore the mediating factors in SOC
(structures and processes), and
•Supply current hospital leaders with actions
they can take to actively monitor and regulate
nurse manager spans of control within their
hospitals.
Span of Control: Clinical, Business Impacts and Solutions • 3
1 Laschinger H, Wong C, McMahon L, Kaufman C. Leader behavior impact on staff nurse empowerment, job tension, and work
effectiveness. Journal of Nursing Administration. 1999;29(5):38-39.
Page 150 of 284
4 • Span of Control: Clinical, Business Impacts and Solutions
Professionally
When it comes to job satisfaction, the good (and
somewhat obvious) news is — a study indicates —
that nurses who are newer in a role as manager have
higher job satisfaction.2 What these new nurse man-
agers may lack in institutional knowledge is made
up by a higher level of enthusiasm and engagement
in the role that leads to the ability to handle larger
SOC. On the ip side, the study also demonstrated
that nurse managers who have been in their position
longer and have a greater SOC report greater dissat-
isfaction. While this nding seems obvious, it argues
against common practices. As a nurse manager
becomes more seasoned in the job, organizations
typically increase SOC at the exact time when his or
her capacity becomes more limited.
Personally
On a personal level for nurse managers, research indi-
cates that a hefty SOC generates considerable stress
— resulting in work-life imbalance, negative health
consequences and more burnout.3 It is disruptive to
unit operations when nurse managers call in sick or
need a leave of absence. One study indicated that job
satisfaction and retention are improved if workload
and SOC are decreased for nurse managers.4
Why do nurse managers stay in the role despite these
challenges? Research shows that overall, nurse
managers care more about patients and staff and
will remain in the job despite feelings of inadequacy,
exhaustion and even failure. They are dedicated to
their work and to patient care.5 One may look at the
research and think that the intention to leave (not
actually leaving, just thinking about it), burnout and
disengagement in the nurse manager could be worse
than it is now. At rst glance, some may justify the fact
that nurse managers are staying as proof that it may
not be that bad. But nurse managers who stay on
board while disengaged and burned out can create a
difcult situation for staff.
NURSING STAFF
The second group impact-
ed by SOC is the staff who
report directly to the nurse
manager. A fundamental
need for any employee is a
personal relationship with
a manager. An employee’s
relationship with his or her
manager is the linchpin of
organizational connected-
ness — it’s the glue that
binds the employee to the organization. This relation-
ship is the reason why most employees stay, and the
lack of a solid relationship is the most frequent reason
that employees leave jobs.
The thinner a manager is spread, the less attention
he or she can give to each employee, weakening that
glue. Even with the most sophisticated, seasoned
and savvy leader in place, staff need face time with
leaders. When a nurse manager tries to have mean-
ingful interactions with 50-200 staff members, the
manager is often overwhelmed. Frequently, a large
SOC leaves staff disconnected from the manager. As
we know, the greater the SOC, the less effective even
strong leaders are. Additional studies show that with
just 10 more workers, managers are less able to build
relationships — leading to greater turnover.6
2 Brown P, Fraser K, Wong CA, Muise M, Cummings G. Factors inuencing intentions to stay and retention of nurse managers:
a systematic review. Journal of Nursing Management. 2013;21(3):459-472.
3 Shirey M. (2009). Stress and coping in nurse managers: a qualitative description [dissertation]. Retrieved from Indiana University
ScholarWorks.
4 Lee H, Cummings GG. Factors inuencing job satisfaction of front line nurse managers: a systematic review. Journal of Nursing
Management. 2008;16(7):768-783.
5 Squires M, Tourangeau A, Laschinger HKS, Doran D. The link between leadership and safety outcomes in hospitals. Journal of
Nursing Management. 2010;18(8):914-925.
6 Lucas V, Laschinger HKS, Wong CA. The impact of emotional intelligent leadership on staff nurse empowerment: the moderating
effect of span of control. Journal of Nursing Management. 2008;16(8):964-973.
Page 151 of 284
Span of Control: Clinical, Business Impacts and Solutions • 5
With many nurse manager SOC’s ranging between
50-200 individuals, every additional 10 direct reports
may seem like a drop in the bucket, but it is important
to recognize the impact of each additional 10 reports
for a manager. Research indicates that for every
increase of 10 individuals in a nurse manager’s SOC,
the turnover rate increases by 1.6 percent.7 This
means if a manager has a SOC of 100, that unit is at
risk for turnover rates around 16 percent.
PATIENTS
The third group is at the center of it all — patients.
If the mission of the industry is to provide the most
exceptional, quality, compassionate care, then the im-
pact of SOC on the patient must be considered. While
patients have
always been
at the heart of
hospital care,
currently the
patient experi-
ence seems to
be at the fore-
front of many
conversations.
Although many
times these two are not directly linked in strategic con-
versations, SOC has an impact on the patient experi-
ence and health outcomes as well.
Per two studies, patient satisfaction is lower in units
where managers have large numbers reporting to
them.6 8 Moreover, larger SOC correlates to adverse
patient outcomes. These results include medication
errors, nosocomial infections, patient falls with in-
juries, staff work related injuries and verbal abuse
toward nurses.9 In addition, it was found that better
nurse stafng was found to be positively associated
with better quality of care.10 Ensuring the best-quality
care means that SOC needs to be a central consider-
ation in hospital operations, not just an afterthought.
MEDIATING FACTORS
While we looked at the outcomes SOC has on various
groups, it’s important to understand that SOC is not
a one-size-ts-all predictive situation. Just because a
manager has a large SOC does not always mean there
will be negative outcomes. There are multiple factors
that can mediate the impact of SOC on these groups.
They can be sorted into structures and processes.
STRUCTURES
The rst factor to consider are the structures in place
that inuence the effects of SOC. This includes the
role of support and administrative staff, as well as the
reporting structures.
Support & Administrative Staff
It’s clear that clinical operations revolve around nurs-
ing staff, but are also dependent on an assortment
of support staff ranging from administrative support
workers to patient care techs and charge nurses — to
ancillary services personnel. The research shows that
these supporting roles help minimize adverse out-
comes and effects of a large SOC.
7 Doran D, McCutcheon AS, Evans M, MacMillan K, Hall LM, Pringle D, Smith S, Valente A. Impact of manager’s span of control on
leadership and performance. Ottawa (Ontario): Canadian Health Services Research Foundation; 2004.
8 McCutcheon AS, Doran D, Evans M, Hall LM, Pringle D. Effects of leadership and span of control on nurses’ job satisfaction and
patient satisfaction. Canadian Journal of Nursing Leadership. Toronto (Ontario): 2009;22(3):48-67.
9 Wong CA, Elliott-Miller P, Laschinger H, Cuddihy M, Meyer RM, Keatings M, Burnett C, Szudy N. Examining the relationships
between span of control and manager job and unit performance outcomes. Journal of Nursing Management. 2015;23(2):156-168.
10 El-Jardali F. Merhi M, Jamal D, Dumit N, Mouro G. Assessment of nurse retention challenges and strategies in Lebanese
hospitals: the perspective of nursing directors. Journal of Nursing Management. 2009;17(4):459-462.
Page 152 of 284
6 • Span of Control: Clinical, Business Impacts and Solutions
Clerical and charge nurse support for the nurse
manager is a critical mitigating factor. A 2012 study
showed that increases in operational and administra-
tive support for front line nurse managers decreased
the negative effect of turnover and vacancies.11
Considering the “soft stuff” for a minute, the reality is
that the soft skills collide with structures in hospitals.
Recent research shows that emotional intelligence
has been identied as incredibly important in health
care environments, but bringing these skills into play
takes strong support structures to measurably affect
outcomes.12
Reporting Structures
The second structures to examine are the reporting
structures within the organization. Dependent on
hierarchical reporting relationships, nursing units
traditionally seek to manage SOC issues in one of
two ways. The rst is to expand the headcount of the
nurse manager, leading to a larger SOC. As we’ve
seen, this leads to negative outcomes. The second
approach is to create more support structures
by increasing management layers (such as charge
nurses). The challenge with this approach is the
resulting layers of leadership impose more “lters”
on messages moving up and down the chain of
command, often impeding communication.
PROCESSES
The second mediating factor to consider are the
processes inside hospitals. These processes are the
technology and other factors that positively and nega-
tively impact the effects of SOC.
Technology
Technology plays a vital role in SOC. While we are far
from robots solely providing patient care, technologi-
cal improvements (EMR implementation, medication
scanners, patient lifts, portable scanners, metrics da-
tabases for nurse managers, etc.), have made nurses
and nurse managers more efcient at doing their job.
Technological improvement and new tools allow for
greater tolerance of SOC for nurse managers. These
technologies can improve the efciency of nurse
managers and staff and create time for patient care.
It was less than 10 to 15 years ago when nurses (and
nurse managers) were still manually charting with pen
and paper.
Hands-on training
and support by
facilities allows
staff to enjoy the
full benets of tools
and technology
while minimizing
risk. At the end of
the day, technology has helped some hospitals, while
it’s been a challenge for others in improving documen-
tation. Some facilities have seen better results than
others in using technology to effectively mitigate SOC.
Other Factors
There are several more factors to consider beyond
structures and processes. The complexity of units
and patient acuity play a role in SOC. Work at The
Ottawa Hospital Research Institute in Ontario, Cana-
da suggests that the level of patient complexity (such
as age, illness level, acuity, duration of care) has an
impact on perceived SOC for nurse managers.13 For
11 Jones D, Gebbens C, McLaughlin M, Brock L. Nurse manager scope and span of control: an objective business and
measurement model. Denver (CO): AONE Annual Conference; 2012.
12 Lucas V, Laschinger HKS, Wong CA. The impact of emotional intelligent leadership on staff nurse empowerment: the moderating
effect of span of control. Journal of Nursing Management. 2008;16(8):964-973.
13 Merrill KC, Pepper G, Blegen M. Managerial span of control: a pilot study comparing departmental complexity and number of
direct reports. Canadian Journal of Nursing Leadership. Toronto (Ontario): 2013;26(3):53-67.
Hands-on training and support by
facilities allows staff to enjoy the full
benets of tools and technology while
minimizing risk.
Page 153 of 284
Span of Control: Clinical, Business Impacts and Solutions • 7
example, researchers found that nurse managers in
an emergency department may require smaller SOCs
due to patient acuity, decisions being more urgent,
and coordination demands and patient turnover.
Furthermore, research shows the physical layout of
a unit is another mediating factor for SOC. If nurse
managers and staff are physically separated, it can
impact the span of control they can effectively man-
age. One study explored the physical environment for
acute care settings and concluded that reducing the
size of larger units or redesigning the subunits resulted
in more effective management when the managers’
SOC averaged 50 direct reports or fewer.14 If a unit
is physically spread out, it can inhibit the ability of a
nurse manager to manage higher volumes. While
there’s no one solution for the physical spread of staff
and rooms in a unit, it’s important to understand that
layout plays a vital role in establishing upper limits for
an effective SOC.
The last “other factor” to consider is the hospital’s
Magnet© status. Magnet status plays a pivotal role,
as one of the key differences for these facilities is the
density of their management structure relative to total
nursing staff. The increased number of nurse leaders
is hypothesized to enhance management’s accessi-
bility, visibility, and responsiveness to staff, which has
been linked to increased job satisfaction in Magnet
hospitals.15
MYTHS & WHAT LEADERS CAN DO
As hospital leaders seek to move the meter in
managing SOC, we must rst look at some myths
about SOC that are out there.
MYTHS
Myth No. 1 — SOC is a concern, but not a large
problem because nurse managers are not complaining.
In general, SOC is parked as a low priority item for
hospitals and it is assumed that whatever SOC is in
place must be manageable since managers and clinical
staff are not complaining (or are not altogether quitting).
Just because high SOCs are accepted as the status quo
does not mean they are a best practice for quality care.
Myth No. 2 — SOC is a human resources (HR) issue.
SOC is no longer just an HR issue. SOC is an important
strategic business issue that needs assessment and
analysis. Through the lenses of leadership and gover-
nance, the heart of the SOC conversation is about risk
tolerance, organizational culture and nancial outcomes
(high turnover rates, linkages to value-based purchasing,
HCAHPS, etc.). All of this means the SOC conversation
must move beyond HR and into the larger conversation
in hospitals.
Myth No. 3 — SOC is a nursing problem. Yes, nursing
has the largest SOC and the largest impact on patients
through clinical outcomes, but organizations would be
naive to not review SOC in other hospital and health
care areas. Administration, ancillary services, environ-
mental services, etc., all play a vital role in supporting
nursing and physicians, as well as inuence the patient
experience and should be considered in the strategic
conversations. An example would be a hospital that
tried decreasing stafng ratios with nurse aides on a
unit with hip and knee patients. The experiment might
affect the unit’s length of stay (LOS) — because of the
impact on nurses’ available time to engage with physical
therapy staff.
14 Ritchey T, Stichler J. Determining the optimal number of patient rooms for an acute care unit. Journal of Nursing Administration.
2008;38(6):262-266.
15 Upenieks VV. The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job
satisfaction. Health Care Management (Frederick): 2003;22(2):83-98.
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8 • Span of Control: Clinical, Business Impacts and Solutions
WHAT LEADERS CAN DO
After thorough review of the research — and consult-
ing with multiple stakeholders, HASC’s Nursing Ad-
visory Council provides three categories for hospital
executives to weigh as they make decisions regarding
SOC. They include evaluating and making changes to
structures, processes and outcomes.
Structures refer to conditions under the current SOC.
They include material resources (facilities, technology
and equipment), human resources (levels of stafng,
qualications, and the role of staff), organizational
characteristics (reporting relationships, levels of
authority, and the dened roles, tasks and functions
of the manager). This step asks what structures are
vital to a facility or organization’s SOC decisions.
Below are a few starting points for beginning the
conversation about structure.
Metrics — To begin, leaders must recognize the
state of their SOC and understand their SOC metrics.
There is a reason the late management guru Peter
Drucker’s “If you can’t measure it, you can’t manage
it” still holds true. Measurable outcomes are vital to
this process. Leaders must understand the state of
their SOC within their hospitals, as well as the im-
pact of SOC on their business decisions. Additionally,
leaders should have a clear understanding of the vital
SOC metrics and indicators to help make informed
business decisions.
Questions to Ask About Metrics:
n Do you know the SOC in all the units in your
hospital? Have you identied “critical units” that
vitally support the bottom line? If so, have you
done a deep dive on SOC in these units?
n Have you explored HR and patient metrics that
would indicate the SOC is ideal or needs
adjusting? These metrics could include turnover,
time to ll positions, engagement scores, LOA/
temporary leave use, HCAHPS, etc.
n Can audit and performance data be provided to
nurse managers rather than expecting them to
pull it together themselves?
Support Structures — One of researchers’ key nd-
ings is the importance of support staff in mitigating
the effects of a burdensome SOC. Mindful of this, it
is important for leaders to evaluate the support struc-
tures in place for nurse managers both administra-
tively and clinically. This includes looking at ancillary
services, organizational charts, administrative sup-
port, etc. This also includes understanding how many
levels a nurse manager is away from the CNO or
COO. Understanding their position inside an organi-
zation, and how they spend their time (not their job
description, but how they actually spend time) is vital
for an accurate read on SOC.
Questions to Ask About Metrics:
n What support roles are currently in place for nurse
managers (unit secretaries, administrative
assistants, educators, clinical supervisors, and
assistant nurse managers)?
n What amount of time are nurse managers spending
on administrative tasks, meetings and other tasks?
n Has the nurse manager’s hours been assessed to
ensure that the best use of their time is being
made?
Operating Structure — When thinking about operat-
ing structures, a mindset must shift from the traditional
hierarchical view of health care past. If leaders adjust
SOC while keeping the same structures in place and
simply adding new layers, they only create taller and
more narrow silos on organizational charts. This area
can present communication challenges. If additional
layers are created, miscommunication is likely as
messages lter up and down the pipeline.
Leaders should consider less traditional, decentral-
ized structures — as these often correlate with orga-
nizational commitment and a climate of professional
trust and respect. What’s more, decentralized struc-
tures combined with exible HR practices can lead to
higher levels of job satisfaction and less turnover.16
These practices are centered on staff training and
development.
16 Weaver CA. Nurses in corporate America: embracing power through inuence. Seminars for Nurse Managers. 2002;10(2):117-119.
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Span of Control: Clinical, Business Impacts and Solutions • 9
Processes are the activities or a series of actions
that lead to outcomes. Organizations can put major
or minor processes in place to support efcient SOC.
Examples of minor processes include limited changes
in policy, practice or protocol — often with inconsistent
outcomes. On the other hand, organizations implement
major processes by dening new and effective tools,
checklists, criteria-driven protocols, auto-prompts in
technological applications, with regularly scheduled
briengs and de-briengs.
Organizations that successfully implement major
processes provide training for nurse managers and
assist them in supervising their departments.
Policies and Procedures — Over the years, many
organizational procedures are left in place because
“it has always been that way.” But, as SOC has in-
creased (in many cases by three to four times), these
policies may not make as much sense any more.
Performance reviews, scheduling, development,
education and training must be evaluated in terms of
effectiveness with the current SOC in each hospital
unit. For example, in large units with 125-plus employ-
ees, many nurses never receive feedback and a fair
performance review from their manager.
Questions to Ask About Policies and Procedures:
n Can high-potential nurses be identied and
developed adequately with a high SOC?
n Can managers build strong enough relationships
with staff to assess talent and create succession
plans?
n Is self-scheduling something that should be
considered for high-functioning units with high
SOCs?
Technology — Business outcomes matter, and the
role of technology in achieving optimal SOC must be
dened. The data shows that leveraging technology
can mitigate effects of heavy SOC. Therefore, the role
of technology should be explored in detail. Hospital
leaders such as the CIO, CNO and COO, along with
nurse directors, must work together to consider how
technology can help nurse managers succeed in pro-
viding exceptional care effectively and efciently.
Any conversation about technology underlines the
need for leaders to support appropriate training,
education and IT support. Generational differences
may also be part of the equation — with more senior
nurses less comfortable with new machines and
systems than younger RNs.
Questions to Ask About Technology:
n Do you have the right technologies in the place to
soften the impact of heavy SOC?
n Are you hiring for technological competence in
the future?
n Are you getting up to speed with industry
technology or lagging behind the curve?
Outcomes. After identifying structures and process-
es, the logical next step is to dene what success
looks like. Outcomes are performance measures that
include human resources, nancial and quality and
patient experience metrics.
Measures of Success — Hospital leaders who are
serious about addressing SOC must take the time to
determine what measures will dene success. The
rst step is identifying HR, nancial, and quality and
patient experience metrics that will accompany im-
provement. These might include reduced turnover,
increased patient satisfaction and/or HCAHPS scores,
improved nancial performance and patient metrics
(like mortality, readmission rates).
Yet identifying metrics is only a rst step. To effectively
use data, the numbers must be consistently tracked
and reported. Trends must be identied to nd ways
to change and improve systems.
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10 • Span of Control: Clinical, Business Impacts and Solutions
Questions to Ask About Measures of Success:
n
What are the organization’s critical business
goals?
n
What metrics do managers need to monitor to
reach those goals?
n
Does a system exist to measure and report
metrics, and look for long-term trends?
n
Can managers query data and metrics without
burdening nurse managers with data requests?
Build the Model — Hospitals should develop a SOC
optimization model that considers a variety of factors.
The model should consider the relationship between
manager and staff, address the complexity of care in
each unit, and assess the capability of the manager
and the staff.
Currently, the most familiar model is The Ottawa
Hospital Span of Control tool.17 This is a statistically-
validated model that assesses various metrics and
provides recommendations on the ideal SOC for a
unit based on multiple factors — such as complexity
of service, hours of operation, support structures and
other factors. Given that the Canadian health care
system is a bit different, it is recommended that this
tool be utilized only as a starting point in the conver-
sation. Then, it’s up to an organization’s managers to
customize the tool to meet specic requirements.
Culture — The X Factor
While it’s important to review structure, processes and
outcomes, we would miss a key point if we didn’t ask
leaders to reect on their organizational culture when
having the SOC conversation. Given that hospitals
operate in a rapidly changing political, economic and
technological environment, it’s essential that leaders
consider their deeply-ingrained cultures. Hospitals
should look not just at their mission and values, but
also at how adaptive and exible their culture is. An
honest appraisal in this regard will be essential in
navigating the many changes sure to happen in
health care.
Organizational culture refers not just to the current
workforce, but to identied adaptive competencies.
These should be built into recruitment and training
practices.
Hospitals cannot predict the many changes the future
will bring, but they can recruit, hire, and support adap-
tive leaders who will navigate these uncertainties and
help their staff do the same.
CONCLUSION
At the end of a white paper on SOC, it would be
great to offer a formulaic solution for optimal SOC.
Yet research repeatedly shows there is no single
metric (or group of metrics) that points to the best
span of control for a unit or organization. Rather, the
most effective and efcient SOC is dependent on
understanding how an organization’s performance
metrics relate to its structures, processes, outcomes
and culture.
There will always be costs associated with large SOC.
The questions that hospital leaders need to wrestle
with include the risks the organization is willing to bear
to take on those costs. Once those challenges have
been determined, strategies to assess, monitor, and
manage them must be put in place.
Finally, it’s important to recognize that the workplace
and employees of the 21st century are different than
previous generations. They do not always take on
the burdens of their predecessors and they will lead
differently. Therefore, it is essential to invest in a new
conversation on how health care businesses are run
today — and how they might be run in the future.
17 Morash R, Brintnell J, Rodger GL. A span of control tool for clinical managers. Canadian Journal of Nursing Leadership. Toronto
(Ontario): 2005;18(3):83-93.
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Span of Control: Clinical, Business Impacts and Solutions • 11
ACKNOWLEDGEMENTS
Members of the HASC Span of Control Subcommittee, listed below, conducted surveys
and research — and worked as a team to complete the white paper.
1. Anna Omery, RN, DNSc, NEA-BC
Senior Director, Clinical Practice
Patient Care Services
Kaiser Permanente Southern California
Anna.K.Omery@kp.org
2. Beverly Quaye, EdD, RN
Assistant Professor
California State University Fullerton
President, No One Walks Alone LLC
beverly@nowa.la
3. Kathy Harren, MSN, MHA, RN, NEA-BC
Nurse Leader
kathy.harren@hotmail.com
4. Ann Dechairo-Marino RN, PhD, NEA-BC
Former Chief Nursing Ofcer, Providence Holy Cross Medical Center
adechairo@roadrunner.com
5. Jim Finkelstein
President and CEO, FutureSense, LLC
jim@futuresense.com
6. Jerry E. Spicer, DNP, RN, NEA-BC, FACHE
Vice President, Kaiser Foundation Hospitals
Regional Patient Care Services - Southern California & Hawaii
Jerry.E.Spicer@kp.org
7. Sheila Repeta (Project Writer)
Senior Consultant, FutureSense, LLC
sheila@futuresense.com
8. Teri Hollingsworth
Vice President, Human Resources Services, HASC
thollingsworth@hasc.org
Special thanks to Kaiser Permanente Southern California for funding this project.
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TITLE PAGE
TITLE: Reexamining Nurse Manager Span of Control with a 21st Century Lens
AUTHORS:
Primary Author: Anna K. Omery, RN, DNSc, NEA-BC
Senior Director, Clinical Practice
Kaiser Permanente Southern California
Regional Patient Care Services
393 E. Walnut Street
Pasadena, CA 91188
Anna.K.Omery@kp.org
Co-Author: Cecelia L. Crawford, DNP, RN
Practice Specialist for Evidence-Based Practice and Program Evaluation
Kaiser Permanente Southern California
Regional Nursing Research Program
393 E. Walnut Street
Pasadena, CA 91188
Cecelia.L.Crawford@kp.org
Co-Author: Ann Dechairo-Marino, PhD, RN, NEA-BC
Former Chief Nursing Officer
Providence Holy Cross Medical Center
15031 Rinaldi Street
Mission Hills, CA 01346
adechairo@roadrunner.com
Co-Author: Beverly S. Quaye, EdD, RN, NEA-BC, FACHE
Assistant Professor
California State University, Fullerton
School of Nursing, EC-190
College of Health and Human Development
800 N. State College Blvd.
Fullerton, CA 92831
Bsquayefullterton.edu
Co-Author: Jim Finkelstein, MBA, BA
President & CEO
FutureSense, LLC
27762 Antonio Parkway, L1-236
Ladera Ranch, CA 92694
jim@futuresense.com
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Reexamining Nurse Manager Span of Control with a 21st Century Lens
ABSTRACT
The primary aim of this integrative review was to examine the quantity, quality, and
consistency of evidence regarding the Span of Control (SOC) specific to Nurse Managers (NMs).
A secondary aim was to meaningfully translate the evidence and offer guidance to 21st Century
executive leaders and NMs. The review results were categorized using Donabedian’s (2003)
Structure-Process-Outcomes (SPO) model. The SPO approach was used to review the literature
and consider SOC recommendations for today’s healthcare environment. Structures outlined the
conditions for current SOC, which included material resources, human resources (HR), and
organizational characteristics. Processes were defined as activities or actions stemming from
identified structures that led to outcomes. Examples included management/administrative
activities, as well as frontline staff participation in these tasks. Outcomes were performance
measures of HR, financial, and quality metrics. The review revealed that a SOC model built on a
simplistic FTE ratio is outdated. Yet, NMs remain in their role in the face of these simplistic
models despite feelings of inadequacy, exhaustion, and failure because they passionately care
about patients and staff (Johansson et al., 2013; Shirey, 2013). New attitudes and integration of
advanced technologies, pioneering tools including SOC assessment tools, and ongoing
competency developments will result in different needs of SOC as healthcare moves deeper into
the modern era (HASC, 2017; Havaei et al., 2015). This evidence is offered to inform and drive
conversations focused on providing optimal NM SOC for maximum effectiveness within unique
and ever evolving care environments.
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8
Table 1.
Literature Review References
Reference
Evidence
Source
Purpose
Conclusions
1. Aiken et
al. (2002)
Multisite
Cross-
sectional
Survey
Examine organizational
support and staffing on nurse
job dissatisfaction, burnout,
quality of care
• Common concerns were dissatisfaction, burnout, quality of care
• Managerial support/adequate staffing play key roles for quality of
care, job dissatisfaction, burnout, and nurse retention
2. Alidina
et al.
(1988)
Case study
Discussion of SOC concept,
structures, implications,
influencing factors
• Optimal SOC is necessary for NM role and responsibilities
• Understanding certain influencing factors can optimize NM SOC
3. Altaffer
(1998)
Descriptive
Survey
Design
Examine FL NM vs. nonNM
scope, SOC, perception of
effectiveness
• NM scored greater effectiveness than nonNM, even though they
supervise more staff, have fewer assistive personnel, and paid less
• Respondents did not rank selves as highly effective in any
dimension; suggests unstable care environment contributes to
negative perception of effectiveness
4. Armstrong
-Stassen et
al. (2003)
Nonexperime
ntal Design
Examine relationship of nurse
personal, job, organizational
dimensions
• Organizational control predicted changes in support and trust
• Although nurses reported low organizational control, more than
one dimension of control is involved in sense of powerlessness
5. Brown et
al. (2013)
Systematic
Review
Explore factors known to
influence NM retention and
intention to stay
• NM retention and intention to stay is multifactoral
• Executive leadership is responsible for support of NM in relation
to SOC, workload, and work/life balance issues
6. Carney
(2004)
Grounded
Theory Study
How organizational structure
aligns/impacts with strategic
management of NM role
• Hierarchy and management layers contribute to NM sense of
exclusion in strategy development
• NM must enable trust and demonstrate leadership by willingness
to work in multidisciplinary care models
7. Cathcart et
al. (2004)
Performance
Improvement
Project
Explore relationships between
SOC and staff engagement
relationships
• Strong relationship between SOC and employee engagement
• Routine review of NM SOC may address negative impact of large
SOC on employee engagement
8. Doran
(2004)
Descriptive
Correlation
Survey
Design
Examine relationships
between NM leadership
styles, SOC, and patient and
nurse outcomes
• No leadership style can overcome a wide span of control
• Executive leadership must develop guidelines regarding number
of staff NM can effectively lead and supervise
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9
9. El-Jardali
et al.
(2009)
Descriptive
Survey
Design
Assess nurse retention
challenges and strategies, as
perceived by Lebanese NM
• Retention challenges include salary, shifts, working hours, better
internal and/or external career opportunities
• Challenges will continue if above issues are not addressed
• More information is needed on NM SOC and leadership/
management capacities
10. Force
(2005)
Literature
Review
Outlines characteristics of
NM leadership style that
enhance nurse retention
• 5 themes: transformational leadership; extroverted personality;
empowerment; autonomy/cohesion; tenure; graduate education
• Themes demonstrate leadership traits lead to nurse job
satisfaction and retention
11. Hansen
et al.
(1995)
Descriptive
Survey
Design
Examine NM personality
traits and staff perceptions of
NM leadership
• Nurses favorably rated NM on leadership style, power, influence
• NM personality modestly linked motivation to manage and select
leadership aspects
12. Johansso
n et al.
(2013)
Comparative
Descriptive
Survey Study
Examine differences in self-
related health between FL
NM and RNs on various
psychosocial factors
• First-line NM can cope with high-demand situations if they have
high control over their work
• High degree of job control and managerial support allows all
nurses to function in stressful work environments
13. Jones et
al. (2012)
Performance
Improvement
Project
Determine how nursing
leadership can improve NM
turnover and vacancy rates
• Redistribution of operational and administrative resources
positively impacted turnover rates, internal transfers, internal
promotions, vacancy rates/days open, NM MSN
• Evaluation of scope/SOC can determine operational and
administrative support tiers needed for NM success
14. Lasching
er et al.
(2005)
Nonexperime
ntal Predictive
Design
Examine effects of
empowerment on staff
perceptions of justice, respect,
trust in management
• Structural empowerment has direct effect on interactional justice,
respect, organizational trust
• NM have pivotal role in creating/maintaining staff trust
15. Lasching
er et al.
(1999)
Nonexperime
ntal Predictive
Design
Examine NM leader
empowering behavior to staff
perceptions of empowerment,
job stress, work effectiveness
• Highlights importance of NM leadership traits within changing
healthcare settings
• NM behaviors impacted perceptions of formal/informal power
and access to empowerment structures
• Higher perceived access linked to lower job tensions and
increased work effectiveness
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10
16. Lee et al.
(2008)
Systematic
Review
Examine determinants of FL
NM job satisfaction
• Addressing SOC, workload, increased supervisor support, and
empowerment may influence FL NM job satisfaction
17. Lewis
(1993)
Expert
Opinion
Case studies describing the
relationship between
empowerment and CQI via
concept of SOC
• Do more, faster: Reduced SOC increases responsiveness, willing
to lead projects, connecting with supportive personnel
• Staff empowerment a dramatic impact on NM SOC
18. Lucas et
al. (2008)
Nonexperime
ntal Predictive
Design
Model linking nurse
perceptions of NM emotional
intelligence leadership style,
structural empowerment,
impact of NM SOC
• NM may not be able to empower their staff if SOC is large, even
if they have strong emotional intelligence
• Senior management must ensure NM have reasonable SOC to
empower staff to full scope of nursing practice and role
19. McCutch
eon et al.
(2009)
Nonexperime
ntal Predictive
Design
Examine relationships
between leadership style, job
satisfaction, patient
satisfaction, SOC, moderating
effect of SOC on above
• Higher SOC decreased positive effects of
transformational/transactional leadership on outcomes
• Management by exception and laissez-faire leadership styles
increased negative impacts on job satisfaction
20. McHugh
et al.
(2013)
Mixed
Methods
(Retrospective
Analysis;
Survey
Design)
Determine if Magnet hospitals
have lower mortality/failure-
to-rescue than non-Magnet
hospitals
• Magnet hospitals had lower mortality/failure-to-rescue odds
• Better work environment is a distinguishing factor between
Magnet/non-Magnet hospitals and key to better outcomes
• Better outcomes partly attributed to investments in qualified
educated nurses and environments supportive of quality care
21. McNeese
-Smith
(1999)
Descriptive
Correlational
Survey
Design
Examine relationship of NM
motivation to leadership
behaviors, staff job
satisfaction, productivity,
organizational commitment,
patient satisfaction
• "Attention of nurses to your condition" positively correlated with
productivity, job satisfaction, organizational commitment, all 5
leadership practices
• NM motivation positively correlated with achievement,
motivation, and 5 leadership practices
22. Morash et
al. (2005)
Mixed
Methods
Study
Design/implement SOC tool
using evidence, surveys, focus
groups, field testing (Ottawa
Hospital Clinical
Management SOC Decision-
Making Indicators TOH tool)
• Tool includes 3 decision-making categories (unit, staff, program-
focused) to classify 8 indicators (unit complexity; material
management; staff volume; skill/ autonomy, stability, diversity;
budgetary, statistical responsibilities
• Need for standardization, EBP changes, assessment of
roles/responsibilities of entire nursing group
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11
23. Patrick et
al. (2006)
Descriptive
Correlational
Survey
Design
Examine relationship between
structural empowerment and
organizational support and
effect on NM role satisfaction
• Combination of organizational support and empowerment are
significant predictors NM role satisfaction
• Perceptions of organizational support may play important role in
retaining NM and attracting future nurse leaders
24. Ritchey
et al
(2008)
Commentary
Determine optimal number of
patient rooms in acute care
settings
• Reduce larger units to subunits/clusters ranging 6 to 12 rooms
• New clusters increased nursing engagement when NM SOC
averaged 50 or less direct reports
25. Shirey et
al (2008)
Secondary
Analysis of a
Descriptive
Survey Study
Thematic examination of
2004 National Critical Care
Survey Findings Report to
determine implications for
nursing administrators
• 4 themes: leadership, practice environment, staffing, and
professional advancement and recognition
• Leadership is about people, relationships, and is transformational
• Assess NM SOC and make appropriate changes in structures
• Monitor the impact of changes in SOC on unit-based and
organizational outcomes
26. Shirey
(2013)
Editorial
Review of a research study
investigating NM stressors
and coping experiences
• Authors allude to two areas for needed intervention: SOC and
therapeutic dialogue
• NM SOC variability is major threat to NM ability to achieve work
satisfaction, engage staff, and affect organizational commitment
27. Wong.
(2012)
Non-
experimental
Predictive
Survey Study
Validate TOH tool and
examine relationships
between FL NM SOC and
manager work outcomes
Manageable SOC essential for quality job/unit outcomes
• Only SOC predicted adverse unit outcomes
• Combination of SOC and self-evaluation predicted job
satisfaction, work control, role overload
• Neither self-evaluation nor SOC predicted unit turnover
28. Wong et
al. (2013)
Mixed
Methods
(Focus Group;
Survey)
Examine combination of FL
NM characteristics and SOC
of job and unit outcomes
• NM report high role overload/job demands, limited job work,
moderate SOC satisfaction
• Increasing system demands contribute to expanded work
responsibilities/role overload
• TOH score significant indicator of NM job satisfaction, job
demands, work control, SOC satisfaction
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12
Table 4.
Recommendations for Constructing Healthcare Systems of the Future
Recommendations
Comments
• Develop a model that drives the positive impacts of NM SOC
(Doran, 2004; El-Jardali et al., 2009; Lucas et al., 2008;
McCutcheon et al., 2009).
• Use The Ottawa Hospital SOC tool to as part of an organizational
assessment to gain a better understanding of required NM SOC
(Morash et al., 2005; Wong et al., 2012; Wong et al., 2013)..
• Develop guidelines and/or tools to support the optimum number of
staff reporting to NM (Alidina & Funke-Furber, 1988; Doran, 2004;
Laschinger et al., 1999; McCutcheon et al., 2009).
• Determine how SOC will impact the NM ability to drive and
support interprofessional care (Doran, 2004; McCutcheon et al.,
2009; Wong et al., 2013).
• Ensure adequate and increasing clerical and clinical support if a
large NM SOC is unavoidable (Jones et al., 2015).
• Reconsider the word “empowerment.” (Laschinger & Finegan,
2005; Lee & Cummings, 2008; Lucas et al., 2008; Patrick &
Laschinger, 2006).
• Link assessment and monitoring of nurse-driven data to NM
outcomes and incentives (Doran et al., 2004; McCutcheon et al.,
2009; McNeese-Smith, 1999), such as value-based purchasing.
• Escalate NM SOC to higher priority levels within executive
leadership (Morash et al., 2005).
• Crosswalk SOC with organizational performance assessment,
career development, policy, and recommendations from reports
such as the Future of Nursing Report (Lee & Cummings, 2008;
Institute of Medicine, 2011; Shirey, 2013; Wong, et al., 2012).
• Model should include assessments of 1) frequency and
intensity of NM-staff relationships, 2) NM-staff
capability, and 3) complexity of the NM unit(s).
• Assessment should include unit complexity; material
management; staff volume; skill/autonomy, stability,
diversity; and budgetary and statistical
responsibilities.
• Supports include hands-on instruction for
new/evolving technology, promoting clinical
advancement, and sustaining coaching and
consultation skills (El-Jardali et al., 2009; Johansson
et al., 2013; Morash et al., 2005; Patrick &
Laschinger, 2006).
• Empowerment concept must be revitalized to reflect
modern NM roles, responsibilities, and practices.
• Do not assume SOC will remain a low priority and
that NM can handle their current SOC because they
don’t complain.
Page 182 of 284
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HEALTH CARE TRANSFORMATION BEGINS WITH YOU!
ACNL
ACADEMY
EXECUTIVE LEADERSHIP
Page 188 of 284
ACNL’s Executive Leadership Academy
An Essential Component to Your Organization’s
Succession Planning Strategy!
MASTERING THE BUSINESS OF HEALTH CARE
A strong, effective and creative executive leadership team is
imperative to conquer the challenges confronting health care
delivery systems today and in the future. Throughout our
nation, health care organizations are constructing
top-tier leadership teams to provide optimal patient care,
lead fiscal operations and create a positive culture.
ACNL’s Executive Leadership Academy is a
transformational learning experience designed to help
nurse leaders excel in executive leadership practice!
This innovative program features a
faculty comprised of California’s
most influential nurse leaders,
academicians and successful
health care executives. The
robust curriculum aligns with
the American Organization
of Nurse Executives (AONE)
competencies; the California
Action Coalition’s integrated
competencies, based on the
Institute of Medicine’s Future of
Nursing Report; and elements of the
Magnet Model for Nursing.
ACNL
ACADEMY
EXECUTIVE LEADERSHIP
A customized program
developed by nurse
leaders. Focus of
presentations is tailored
to meet the unique
needs of participants.
4 More information and online application at www.acnl.org
Blending Cutting-Edge Curriculum with Practical Application
This 12-month program builds and advances leadership competencies by educating and coaching
attendees to:
>>
LEAD PEOPLE through authentic communication and reflective practice skills.
>>
BUILD COALITIONS through teamwork, political influence and conflict management.
>>
DRIVE CHANGE by creating a vision, embracing evidence-based practice and quality improvement, and
improving awareness of critical legal and regulatory factors.
>>
LEAD INNOVATION with fiscal and environmental stewardship and understanding of technology and informatics.
>>
ATTAIN A GLOBAL PERSPECTIVE to enrich your personal leadership toolkit.
Page 189 of 284
UNIQUE FEATURES OF ACNL’S EXECUTIVE
LEADERSHIP ACADEMY
n A 360-degree assessment by a certified coach with the development of a personal
learning/action plan geared to your unique talents and goals.
n Collaboration with an Executive Nurse Leader Mentor via the LifeMoxie platform.
n A capstone quality improvement project to benefit your sponsoring institution.
n Internal champion to guide you through organizational politics and advise you in
development of your capstone project.
n Cohort experience and networking with California health care leaders.
n Speaker series and leadership case studies to enhance application of key concepts.
n ELA Book Club to expand your knowledge and share ideas with your community of
leadership colleagues.
n An Executive Leadership Certificate presented by ACNL upon successful completion of
the ELA program.
CONTINUING
EDUCATION CREDIT
This program will provide
continuing education credit
through the California
Board of Registered Nursing
and the American Nurses
Credentialing Center.
More information
to come…
Page 190 of 284
EXECUTIVE LEADERSHIP
ACADEMY OBJECTIVES
n Employ strategic thinking and decision-
making in your leadership practice.
n Analyze the principles of complex
leadership and their effective
application within health care
organizations.
n Apply contemporary strategies to
effectively lead change.
n Develop high performance
communication skills, including inspiring
a shared vision, promoting shared
decision-making within interprofessional
teams, utilizing advanced negotiation
tactics to optimize results and
effectively resolving conflict.
n Use evidence-based approaches to
create a culture of innovation within
your organization.
n Identify and maximize your personal
leadership style.
2520 Venture Oaks Way, Suite 210 | Sacramento, CA 95833 | 916-779-6949 | www.acnl.org
EXECUTIVE LEADERSHIP
ACADEMY OVERVIEW
ACNL’s Executive Leadership Academy effectively blends didactic
and mentorship learning throughout the 12-month program.
Participants will come together for learning intensives four times
during the program. One of these in-person intensives will coincide
with ACNL’s Annual Conference in February. In addition, there
will be required readings, recorded lectures, synchronous and
asynchronous webinars, and group dialogue via discussion boards.
This exclusive program is limited to 20 participants.
WHO SHOULD ATTEND?
ACNL’s Executive Leadership Academy is designed for nurse
leaders from across the continuum, including acute care, post-
acute, ambulatory care, community health, academia and other
settings.
• Nurse leaders new to the executive leadership role.
• Senior nurse leaders aspiring to attain executive leadership
positions.
• Seasoned nurse leaders identified by their organizations as rising
stars as part of the succession planning process.
Don’t miss this outstanding opportunity.
Enroll today in ACNL’s Executive Leadership Academy!
APPLICATION PROCESS
Submit your online application, including one letter of
recommendation, a personal statement related to your future
career goals and a curriculum vitae. Program includes a 360-degree
assessment and individualized learning plan by a certified coach,
program materials and ACNL annual conference registration during
the year of enrollment.
Preference given to ACNL members.
REALIZE YOUR FULL POTENTIAL AS A LEADER
Advance Your Career to the Next Level!
Attend ACNL’s Executive Leadership Academy!
To excel as a leader, you must develop a balance of strengths
across a wide range of critical competencies. As you build these
strengths, you maximize your effectiveness and performance,
while increasing your personal engagement and job satisfaction.
More information and online
application at www.acnl.org
Page 191 of 284
Building a “Foundation
for Leadership Excellence”
Creating a Community
Nurse Leaders
of
PRESENTED BY THE ASSOCIATION OF CALIFORNIA NURSE LEADERS
Five full days of learning, problem-solving and networking
See inside for details about this comprehensive program
FIVE-DAY
CURRICULUM
CUTTING EDGE
CURRICULUM
WITH PRACTICAL
APPLICATIONS
TO SUCCEED AS A
LEADER IN TODAY’S
HEALTH CARE
ENVIRONMENT.
Page 192 of 284
Our health care environment is changing rapidly.
Health care reform, pay for performance, HCAHPS,
value based purchasing, quality, patient safety and
other critical initiatives are vital to the success of
your healthcare organization and your ability to
provide optimal patient care.
As a nurse manager, you are at the heart of today’s
healthcare operations. You play a pivotal role in
recruiting, retaining and motivating staff; ensuring
clinical quality; managing both fiscal operations and
services to patients; as well as many other areas of
responsibility. Foundation for Leadership Excellence was
created to provide nurse managers and front-line
leaders with the tools they need to be successful.
Since its inception, the Foundation program has
evolved to meet the changing needs of nurse leaders.
Foundation for Leadership Excellence is a five-day
intensive program to help you develop long-lasting,
effective leadership skills. Whether it’s human
resource issues, customer-service concerns,
implementation of quality and patient safety
initiatives, budget analysis, cost-saving mandates or
building your influence as a leader, you will gain new
perspectives and solutions for the difficult challenges
you face on a daily basis.
This program provides emerging and seasoned nurse
leaders with many opportunities to acquire new skills
and build upon existing ones – a winning formula for
success!
In keeping with our
Lifelong Learning philosophy,
the course curriculum provides an
excellent foundation as emerging nurse
leaders prepare for national certification
through the American Organization
of Nurse Executives’ (AONE)
Credentialing Center.
THIS COMPREHENSIVE
PROGRAM OFFERS:
n A faculty comprised of California’s most influential nurse leaders.
n Exploration of trends in professional nursing practice, health care
and leadership and their impact on your work environment.
n Opportunities to build invaluable professional relationships.
n Practical approaches, tools and innovative techniques to help you
problem-solve in your professional setting.
n Integration of your specific questions and interests into the course
content with practical solutions to your real-time challenges.
n Interpretation and analysis of budget and financial statements and
defined implications specific to your unique circumstances.
n Implications of regulatory and legislative health policy on leadership
and practice.
OVERALL COURSE OBJECTIVES
n Explore innovations in nursing practice and leadership.
n Identify and grow your personal leadership style to increase your
influence and effectiveness.
n Develop strategies to build a positive work environment with
motivated employees where optimal inter-professional practice
flourishes.
n Examine proven approaches to enhance customer service and
patient engagement to increase HCAHPS and CGCAHPS scores.
n Utilize business plans and financial reports to drive decision-making.
n Integrate performance-improvement, regulatory and accrediting
principles into your leadership role.
n Discover the nurse leader’s role in health care reform and the
institute of Medicine’s Future of Nursing vision.
n Discuss implications of policy decisions on nursing practice and
patient care.
n Develop proficiency in providing meaningful feedback to employees.
n Devise strategies to effectively lead and manage change.
n Re-energize your spirit to be the best leader possible.
A FIVE-DAY PROGRAM DESIGNED FOR NURSE LEADERS
Foundation for Leadership Excellence
THE ASSOCIATION OF CALIFORNIA NURSE LEADERS PRESENTS:
“Promotes a very positive and engaging environment that inspires
me to be the best manager possible!”
Page 193 of 284
COURSE
OFFERINGS AND
REGISTRATION
For course offerings,
hotel information and to
register for Foundation
for Leadership Excellence,
see the enclosed
Registration Form or
visit the ACNL website
at www.acnl.org
PROGRAM AT A GLANCE
D A Y 1 — Leadership Excellence
n Learn key competencies and behaviors of successful leaders.
n Apply insights of assessment to improve your leadership
skills.
n Use leadership principles to balance clinical and business
agendas.
n Understand the far-reaching impact of systems theory.
n Explore personality traits to enhance your communication
and leadership skills.
DAY 2 — Raising Your Financial and Leadership IQ
n Examine opportunities to improve the health of our
patients and communities through the IOM Future of
Nursing vision and the Affordable Care Act.
n Develop a working knowledge of Value Based Purchasing
and how your leadership can impact the financial
performance of your organization.
n Enhance your communication abilities for all situations.
n Examine generational and cultural differences in the
workplace and their impact on leadership effectiveness.
n Understand all components of budget, including position
control and interpreting financial statements.
n Explore the facets of financial leadership, including
accountability, variance analysis, cost/quality/service and
operational efficiency.
DAY 3 — The Influential Leader: Maximizing Your
Resources
n Explore the essentials of successful budget planning.
n Discover the fundamentals of business plan development
and presenting your plan to decision-makers.
n Improve your negotiation skills to achieve your goals and
increase your influence.
n Create your personal plan to maximize your career
potential.
Graduates of Fall 2015 Foundations Course.
DAY 4 — Leading Your Team: Setting Expectations
and Enhancing Performance
n Increase team effectiveness and efficiency by selecting and
retaining quality talent.
n Understand the nurse leader’s role in monitoring and leading
professional practice.
n Formulate strategies to maximize staff performance,
including setting expectations, handling discipline and
providing objective behavioral feedback to employees.
n Manage conflict, disruptive behavior and bullying in the
workplace.
DAY 5 — Putting it all Together: Quality and Patient
Safety Begins with Your Leadership
n Describe key factors to consider when managing in a union/
potential union environment.
n Explore national trends in performance improvement.
n Understand the nurse manager’s role in an environment.
where patient outcomes are linked to reimbursement.
n Identify practical strategies and tools to improve outcomes
and successfully lead change.
n Learn to engage staff to improve customer service and raise
HCAHPS and CGCAHPS scores.
n Reflect on lessons learned and integrate skills gathered
throughout the Foundation Course.
CONTINUING
EDUCATION CREDIT
Provider approved by
the California Board of
Registered Nursing, Provider
No. 02110, for 40 contact
hours. Three units of
University graduate elective
credits are available through
California State University,
San Marcos. Contact ACNL
for more information.
WHO SHOULD ATTEND?
Nurses in leadership roles and those who aspire to leadership
across the continuum, including acute care, post acute and
ambulatory care, are encouraged to attend this program.
“Best conference in my nursing career!
The subject variety was wonderful.”
“I thoroughly enjoyed the course and feel better prepared
for my new management role.”
“This conference is empowering!”
“Every nurse leader needs to attend this conference.” Page 194 of 284
For course offerings, hotel information and to register for Foundation for Leadership
Excellence, see the enclosed Registration Form or visit the ACNL website at www.acnl.org.
Judee Berg, MS, RN, FACHE
Judee is executive director of HealthImpact, formerly
the California Institute for Nursing & Health Care,
which develops solutions to meet nursing workforce
needs. She has held hospital, nurse executive and
leadership positions in state and national health care
organizations, and is a past president of ACNL.
Brenda Brozek, MAOL, RN
Brenda is a communication and education consultant
for several professional nursing organizations,
including ACNL. She specializes in helping groups and
individuals effectively deliver their messages to a
variety of audiences. Brenda is a published author and
former executive director of ACNL.
Kathy Cocking, MSN, RN
Kathy is director of clinical services at Carson Valley
Medical Center. With more than 30 years of health
care experience, she has served in a variety of nursing
and leadership roles. A creative nurse leader, Kathy
formed the first online associate degree RN program
in California in collaboration with a local college.
Peggy Diller, MS, RN
Having been a California nurse executive for more
than 20 years, Peggy‘s current niche is serving in
interim nursing executive positions. She has been the
senior nurse leader in hospitals across the state – in
both union and non-union environments. Peggy is a
past president of ACNL.
Mary Foley, PhD, RN, FAAN
Mary is director of the Center for Nursing Research
and Innovation at UC San Francisco. She is active in
the health policy arena and is a past president of the
American Nurses Association. Mary has worked with
the Collaborative Alliance for Nursing Outcomes
(CALNOC) since 2004, and has extensive expertise
in nurse sensitive care measures.
Beth Gardner, MS, RN
As a seasoned nurse executive, Beth has extensive
experience in nursing and hospital operations. She is
an enthusiastic and collaborative leader with strong
communication and team building skills. Beth is a
champion for the nursing profession and is a past
president of ACNL.
Kimberly Horton, DHA, MSN, FNP, RN, FACHE
Dr. Horton is chief executive officer at Vibra Hospital
of Sacramento. Prior to joining Vibra, she held
numerous leadership roles in public and private health
care systems. A successful strategist, role model and
mentor, Kim is passionate about nursing’s role in
health care reform, leadership, professional ethics and
lifelong learning.
C O R E F A C U L T Y
“Every speaker has a passion for their subject
that resonates throughout the room.”
Judy Husted, MS, RN
Judy has more than 30 years of senior healthcare
leadership experience in for-profit, not-for-profit and
HMO organizations. She has had much success in
optimizing operations, enhancing profitability and
driving organizational performance. Judy has been
active in ACNL since its inception, serving as
president in 2003.
Dennis Kneeppel,
MPA, RN, FACHE, CPHQ, NEA-BC
Dennis is chief operating officer and chief nursing
officer at Kaiser Permanente San Rafael Medical
Center. Dennis is a champion for the nursing
profession and quality patient care. He has a strong
background in administrative and critical care nursing
as well as clinical informatics.
Ginger Manss, MSN, RN, AOCN
Ginger is senior director of quality and patient
engagement at St. Joseph’s Medical Center in
Stockton. She has more than 30 years of clinical
nursing and administrative experience and is an
energetic and passionate leader. Ginger is also a past
ACNL president.
Patricia McFarland, MS, RN, FAAN
Pat is the chief executive officer of ACNL,
representing the voice of nurse leaders throughout
the state. She also serves as the executive officer for
the California Nursing Students’ Association and
California Association of Colleges of Nursing. Pat is
the 2014 recipient of AONE’s prestigious Nurse
Mentor Award.
Catherine Robinson-Walker, MBA, MCC
Catherine is the president of The Leadership Studio,
an Oakland firm that specializes in reviewing health
care organizations, teams and individuals for greater
engagement, effectiveness and success. She is an
executive coach, team facilitator and author.
Catherine’s newest book is: Leading Valiantly in
Healthcare.
Lynne Whaley-Welty, MS, RN
Lynne is formerly senior vice president for clinical
operations/chief nurse executive at White Memorial
Hospital, part of the Adventist Health System. With
more than 30 years of nursing, clinical and
administrative experience, Lynne is a champion of the
nursing profession and patient care excellence. She
has successfully mentored nurse leaders at all levels.
Page 195 of 284
Name: Last ____________________________________________First _______________________________________________
Title __________________________________________________Nickname for Badge _________________________________
Organization _______________________________________________________________________________________________
Mailing Address ________________________________________City, State, Zip ______________________________________
Daytime Phone ________________________________________Fax Number ________________________________________
E-Mail _________________________________________________RN License Number for CEUs _________________________
CONFERENCE LOCATION
Program registration begins at 7:30 a.m. on Monday, and the program ends at
3:30 p.m. on Friday. All sessions begin at 8 a.m.
REGISTRATION FEES
AMOUNT
: $1,450 (includes conference materials and lunch each day) $ _______________
Two or more from the same facility and mailed together: $1,400 each $ _______________
(Must be mailed together — NO EXCEPTIONS.)
**SPECIAL OFFER FOR FOUNDATION ATTENDEES:
50% ACNL Membership Discount: $105 for your first year as a
Regular Member or $65 for first year in the Emerging Nurse Leader
membership category (less than 2 years in formal leadership position) $ _______________
Complete ACNL membership application.
TOTAL AMOUNT $ _______________
PAYMENT
Method of Payment q Check q Credit Card (Visa/MasterCard/Discover)
Credit Card Number _________________________________________ CVV Code _______ Expiration Date ______________
Name on Card ___________________________________________ Signature ________________________________________
Billing Address ___________________________________________________________________________Zip_______________
Make checks payable to ACNL and mail to:
ACNL, 2520 Venture Oaks Way, Suite 210, Sacramento, CA 95833
For more information, call 916-779-6949.
**Participants in Foundation for Leadership Excellence are eligible to join ACNL at a
50% discounted membership fee for their first year of membership!
TO REGISTER: MAIL: ACNL,
2520 Venture Oaks Way, Suite 210, Sacramento, CA 95833
FAX: 916-779-6945
ONLINE: www.acnl.org
2 0 1 8 R E G I S T R A T I O N F O R M
HOTEL INFORMATION
November 12-16, 2018
Embassy Suites – Anaheim South
11767 Harbor Blvd.
Garden Grove, CA 92840
Conferences at the Embassy
Suites include full breakfasts and
a complimentary evening cocktail
reception for attendees staying at
Embassy Suites
Single occupancy: $152
Double occupancy: $162
Use the URL below to make
your hotel reservations for the
November 2018 Course:
http://embassysuites.hilton.com/
en/es/groups/personalized/L/
L A XGDE S- ACN -20181111/ ind ex .
jhtml
For questions about your room
reservation, contact Helms Briscoe
at 928-252-3544.
CANCELLATIONS
Registration fees, less a $300
cancellation fee, are refundable if
written notice is received 14 days
prior to the conference. Registrant
substitutions are encouraged.
ADA INFORMATION
If you require special meals or
accommodations pursuant to
the Americans with Disabilities Act,
please call ACNL at 916-779-6949.
PRE-COURSE HOMEWORK
ASSIGNMENTS
In order to maximize your
experience in the Foundation for
Leadership Excellence program, a
homework assignment with pre-
reading will be sent to you prior to
your attendance at the course.
q November 12-16, 2018
Embassy Suites – Anaheim South
11767 Harbor Blvd., Garden Grove, CA 92840
Page 196 of 284
e professional nursing organization
that develops nurse leaders, advances
professional practice, influences
health policy and promotes quality
health care and patient safety.
Kim Tomasi, MSN, RN
Chief Executive Officer
Wendy Smolich
Administrative Manager
2520 Venture Oaks Way, Suite 210
Sacramento, CA 95833
Phone: (916) 779-6949
Fax: (916) 779-6945
kim@acnl.org
wendy@acnl.org
www.acnl.org
Benefits of ACNL
Membership
ACNL is a powerful resource and voice for you as a
nurse leader. By becoming an ACNL member, you
gain access to many benefits and services to help you
succeed in your role, including:
• Collective voice to influence the future
of health care.
• Network of experienced nurse leaders and mentors.
• Tools and knowledge to effectively manage the
challenges and complexities in the nursing
practice environment.
• Sharing of best practices in leadership, quality,
patient safety and other key areas.
• Exceptional leadership programs and educational
opportunities.
• Wide range of sources for essential and timely
information
–
website, publications, toolkits,
e-mail blasts and regional meetings are just a few
of the resources available.
• Access to ACNL’s Mentorship Program through
LifeMoxie, a virtual platform featuring tools and
resources for all levels of nurse leaders.
• Scholarships to promote lifelong learning and
professional development.
• Discounts on ACNL programs and services
…and MUCH MORE!
ACNL helps YOU succeed as a Nurse Leader!
Positioning nurse leaders to create and
influence the future of health care.
ACNL: Transforming nurse
leadership through education,
mentoring and opportunities
for professional growth.
“ACNL is the best single resource
for information on professional
issues confronting nursing.”
“ACNL is a professional
organization that is in the
forefront of change in nursing.”
Page 197 of 284
ACNL: Leading
the Way
For more than 40 years, the Association of
California Nurse Leaders has been living its vision
of positioning nurse leaders to create and influence
the future of health care. ACNL is a powerful
voice for nurse leaders throughout California
and serves as a statewide and national example of
affecting positive change for nursing and health
care by developing nurse leaders, advancing the
professional practice of
nursing and improving
the health of California’s
communities.
Our members are diverse
in their experience and
talents. ACNL seeks
the active engagement
and participation of all
its members. rough
this collective strength,
nurse leaders can best
meet the needs of their organizations, clients and
communities, while at the same time, advance the
profession and practice of nursing.
If you’re a nurse leader, or aspiring to be one,
ACNL is the organization for you!
WHO Should Join
ACNL?
Regardless of where you are on the leadership
continuum, ACNL provides you with a wide variety
of professional opportunities: Access to information,
resources and best practices; Leadership
Development through outstanding educational
offerings; Strategic Partnerships to advance
nursing leadership; Networking opportunities with
experienced nurse leaders and a Voice in health care
policy and other important issues.
ACNL Membership Categories:
• Regular Membership
For current nurse leaders.
• Emerging Nurse Leader
For aspiring nurse leaders or those in a formal
leadership position less than 2 years.
• Emeritus Membership
Must be an active ACNL
member for 5 years or more,
age 62 or older and working
less than 25% time.
• Affiliate Membership
For RNs maintaining active
membership in a California
organization affiliated with
ACNL through an agreed
partnership.
• Associate Membership
For fulltime students and newly licensed RNs.
• Professional Colleague
Established in recognition of the support and influence
of health care leaders who are not nurses.
Kim Tomasi, MSN, RN
Chief Executive Officer, ACNL
Kimberly Horton, DHA, MSN,
FNP, RN, FACHE
2019 ACNL President
ACNL: Transforming
Nurse Leadership
rough our many programs
and initiatives, ACNL is
committed to helping you
succeed in your role as a
nurse leader.
Education
–
cutting edge
educational and professional
development opportunities:
• Annual Conference
–
featuring nationally
recognized speakers, state of the art products and
services, and vital networking opportunities.
• Foundation for Leadership Excellence
–
a 5-day
comprehensive program for emerging nurse leaders.
• Professional Development
–
opportunities to share
ideas, resources and best practices.
• Executive Leadership Academy
–
a transformational
learning experience preparing nurse leaders for
executive roles.
• Webinars featuring innovations and current issues
impacting health care.
Health Policy
–
committed to health care reform in
collaboration with major stakeholders.
Professional Practice
–
key collaborators to
implement the recommendations of the Institute of
Medicine’s Future of Nursing Initiative. Resources for
building healthy work environments.
Research
–
using evidence to drive leadership and
nursing practice.
Mentorship
–
ACNL offers a state of the art, virtual
mentorship program for all levels of nurse leaders.
Lifelong Learning
–
scholarships to support the
education of nurse leaders; tuition discounts at ACNL
partner universities.
“ACNL is a place to get involved
and make a difference!”
Dennis Kneeppel, MPA, RN,
FACHE, CPHQ, NEA-BC
2018 ACNL President
“My engagement with ACNL
has opened many doors and
helped tremendously in my
professional growth!”
Giancarlo Lyle-Edrosolo, DNP, RN, CENP, CNL
Page 198 of 284
GLENDALE NEWS-PRESS NEWS
GLENDALE NEWS-PRESS
Glendale Community College nursing program helps fill critical care gap
By ANDREW J. CAMPA
JUL 13, 2018 | 1:45 PM
For eight weeks this summer, innovation meets enterprise at the Glendale Community College nursing
program.
The department is conducting a coveted critical care course that ends Aug. 15 and has drawn attention
throughout the state.
Glendale nursing division chair Emelyn Judge pushed for a Strong Workforce Program grant, an offering
created in 2016 for which the state set aside $248 million to allow community colleges to launch career
technical education.
“There are shortages in California for specialized nursing and this class helps fit that need,” Judge said.
“We’ve gone to different meetings with hospital associations and have heard about education issues.”
Judge said Glendale Community College received $800,000 for CTE classes, headed by Jan Swinton, dean
of Workforce Development.
Judge secured a portion of that funding to develop a specialized critical care class open to licensed
registered nurses.
The weekly class meets from 7 a.m. to 3:30 p.m. on Wednesdays. It got underway June 20.
Participants pay $275 for the class and books but have that fee reimbursed upon successful completion.
On top of training, nurses can earn electrocardiogram certification and earn 60 hours of continuing
education units. The California Board of Registered Nursing requires 30 hours of continuing education
every two years for nursing license and certificate renewal.
On a recent Wednesday, a packed class receives a guest lecture from Drew Martenson, White Memorial
Hospital respiratory manager.
Martenson is conducting a lesson on basic ventilator settings and goes over ventilation and oxygenation.
“There are shortages in California for specialized nursing and this class helps fit that need.”
GLENDALE NURSING DIVISION CHAIR EMELYN JUDGE
Page 199 of 284
The demonstration is taking place in a studio that’s half classroom, half realistic-looking hospital critical
care ward complete with special beds, a new ventilator and three medical mannequins that range from
$60,000 to $80,000.
The lifelike and slightly eerie-looking bodies are used to practice cleaning wounds, offering treatment
and even delivering birth.
Down the hallway is another room that’s set up as half computer lab and half hospital setting.
Judge said the temporary course was created to help meet a need in specialty nursing.
Hospital Assn. of Southern California and HealthImpact, a nursing agency, released an executive
summary in 2016 stating an expected shortage of nurses statewide in the fields of critical care (2,230),
emergency (1,392), perioperative (1,072), labor and delivery (864) and neonatal intensive care unit (688)
for 2017.
One of the study’s key findings noted that the lack of qualified nurses was partially due to an
“insufficient pre-licensure education specific to specialties.”
So sparse is training that Glendale’s course drew students from afar.
“I saw a posting about this class on Facebook and I shared it with my friend,” said San Francisco resident
Meauyie Guan. “It’s rare to have this kind of class focused on critical care.”
Guan and her South San Francisco ally Caitlyn Chi, who met working at Crossroads Home Health and
Hospice in San Francisco, fly in every Tuesday before midnight to attend the daylong class and return
home Wednesday evening.
White Memorial Hospital Respiratory Manager Drew Martenson, right, teaches a Ventilator Competency
class as GCC associate professor Karima Esmail, left, pays notice during the critical care course at
Glendale Community College on Wednesday. The course is for registered nurses. (Raul Roa/Staff
Photographer)
“The only other option was a virtual class without a classroom and instructor,” Chi said. “You can’t ask
questions, you can’t interact. Plus, that class charges like five times the amount of this class.”
A little closer to the Jewel City, 2016 GCC nursing graduate Karen Staron didn’t need convincing.
“Having the Glendale [Community] College nursing program behind this program, I knew it would be
excellent,” said Staron, who works at the Alhambra Behavioral Health Center. “Because I graduated
from this program, they instill in you to keep up with your education. This gave me a chance to get a
head start on my CEU units. Plus, this is 10 minutes from my house.”
A robust and diverse class is something Glendale Assistant Nursing Program Director Michelle Ramirez
Saelak believes is positive.
Page 200 of 284
“Having worked here for the last 12 years, I pride myself on quality,” Ramirez Saelak said. “It’s hard
being the guinea pigs, but then when you see someone flying in you know you better not waste their
time. You know that your game needs to be on.”
Judge says there is likely enough grant money for the course to be conducted another summer, but her
long-term goal is to get the class approved as a credit course.
“It’s a project and hope of mine,” Judge said. “It just takes a while and there’s a lot of paperwork, but
there’s definitely a need.”
Andrew J. Campa
CONTACT
Andrew J. Campa covers education for the Burbank Leader and Glendale News-Press. He has been a
reporter for Times Community News since 2011 and previously covered high school and college sports,
and has written the occasional professional sports feature. Previously, Campa worked at the Whittier
Daily News and Pasadena Star-News. He’s a proud Cal State Fullerton (#tusksup) and Pasadena City
College alumnus. He hopes the Chicago Bears will get back to the Super Bowl one day.
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[Type here]
No Place Like Home: Advancing
the Safety of Care in the Home
Report of an Expert Panel Convened by the
Institute for Healthcare Improvement
AN IHI RESOURCE
53 State Street, 19th Floor, Boston, MA 02109 • ihi.org
No Place Like Home: Advancing the Safety of Care in the Home. Boston, Massachusetts: Institute for Healthcare Improvement; 2018.
(Available at ihi.org)
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The Institute for Healthcare Improvement (IHI) is a leading innovator in health and health care improvement worldwide. For more than 25 years, we have
partnered with visionaries, leaders, and frontline practitioners around the globe to spark bold, inventive ways to improve the health of individuals and
populations. Recognized as an innovator, convener, trustworthy partner, and driver of results, we are the first place to turn for expertise, help, and
encouragement for anyone, anywhere who wants to change health and health care profoundly for the better.
The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) began working together as one organization in May
2017. The newly formed entity is committed to using its combined knowledge and resources to focus and energize the patient safety agenda in order to
build systems of safety across the continuum of care. To learn more about our trainings, resources, and practical applications, visit ihi.org/PatientSafety
Copyright © 2018 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents
are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form
or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement.
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Institute for Healthcare Improvement / National Patient Safety Foundation • ihi.org 3
Contents
Executive Summary 4
Acknowledgments 7
The Imperative to Improve Home Care Safety 11
The Focus of This Report 16
Key Types of Harm in the Home Setting 24
The Existing Foundation for Care in the Home 29
Guiding Principles 30
Recommendations 34
Conclusion 46
References 47
Appendix A: Case Studies 53
Community Aging in Place: Advancing Better Living for Elders (CAPABLE) 53
Community Care of North Carolina: CPESN® Network 56
Hospital at Home® 59
MedStar Mobile Healthcare: Mobile Integrated Healthcare 62
North Dakota Dementia Care Services Program 66
Operation Family Caregiver 69
Program of All-Inclusive Care for the Elderly (PACE) 72
Pharm2Pharm: Pharmacist-to-Pharmacist Care Transitions Program 74
References for Appendix A 79
Appendix B: Suggested Tactics for Advancing Medication Safety in the Home 82
75
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Executive Summary
There truly is no place like home, and care in the home holds many potential benefits, including
support for person-centered care. Care recipients generally prefer to be at home, where they may
have more autonomy than in inpatient settings. Care in the home is not without its challenges,
however, and these challenges may affect both care recipients and everyone who supports them.
Existing data suggest that preventable harm to care recipients is an important issue in the home
setting. In addition, both home care workers and family caregivers may be physically or
emotionally harmed as they provide care.
The safety of care provided in the home has not yet received nearly as much attention as patient
safety in hospitals and other clinical settings, despite the fact that the home has become the site of
care for many people. In 2016, more than 2 million personal care attendants provided care in the
home, according to the US Department of Labor, and this number is expected to grow by 40
percent in the next decade.1 Care in the home comprises a number of different services, including
personal care, home health care, hospice, palliative care, and, through some specialized programs,
primary care and hospital-level services. These services are provided by a variety of home care
workers with a range of training and expertise. In addition, many aspects of care are provided by
family caregivers.
The Institute for Healthcare Improvement (IHI) convened an expert panel in November 2017 to
consider the specific challenges to safety in the home setting and to offer recommendations for
improvement. This report describes the panel’s feedback and generally focuses on safety related
to two primary aspects of care in the home: personal care and home health care (see box on page
14 for the definitions used in this report). It considers the physical and emotional safety of the
care recipient, the family caregiver, and the home care worker, while recognizing the
interconnected nature of the safety of all these individuals. The goal of this work is optimizing
safe, person-centered care for the unique environment of the home.
The panel found that a number of factors make safe care in the home especially challenging:
1) The provision of care outside the controlled environment of the health care system
2) Issues with communication and care coordination among the care team, the care recipient,
and the family caregiver
3) The need to balance autonomy and risk
4) The closeness of the link between the care recipient and those providing care
5) The limited health literacy of the care recipient and the family caregiver
6) Variable availability of data
7) Social and physical isolation
8) The variety of needs and populations
Safety interventions used in other settings cannot simply be applied to meet the specific challenges of
safety in the home setting. Understanding the type and scope of the risks specific to care in the home is
essential to identifying effective strategies for mitigating risks and optimizing well-being for people
who receive care in their homes. These risks include the following potential harms:
1) Adverse events related to medication and other forms of treatment
2) Injuries due to physical hazards in the home (e.g., falls)
3) Injuries related to equipment and technology
4) Pressure injuries
5) Infections
6) Conditions related to poor nutrition
7) Adverse effects on family caregivers
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8) Adverse effects on home care workers
9) Potential neglect and abuse of care recipients
These harms and their underlying causes are interrelated. For example, medications may lead to
dizziness or unsteady gait, raising the risk of falling — a risk also heightened in a poorly designed
physical environment (e.g., a home with scatter rugs and no grab bars).
To date, we do not yet have a full understanding of the nature and prevalence of risks in the home
and optimal ways to improve safety in that setting, but we do have a strong foundation for
advancing safety. Over the past several decades, home health care and hospice and palliative care
are two of the many fields that have contributed to this foundation, and any strategies to advance
the safety of care in the home going forward must recognize and build on that foundation.
The panel identified five guiding principles to advance the safety of care in the home, as well as
recommendations and specific strategies and tools to put these principles into action (see box
below).
Five Guiding Principles for Advancing Home Care Safety
Principle 1: Self-determination and person-centered care are fundamental
to all aspects of care in the home setting.
o Recommendation 1.1: Improve communication with care recipients and family caregivers.
o Recommendation 1.2: Provide meaningful, relevant education for care recipients and
family caregivers.
o Recommendation 1.3: Develop tools to improve person-centeredness in systems of care.
Principle 2: Every organization providing care in the home must create and
maintain a safety culture.
o Recommendation 2.1: Create a vision for a safety culture in the home health and
personal care fields.
o Recommendation 2.2: Ensure the emotional and physical safety of family caregivers and
home care workers.
Principle 3: A robust learning and improvement system is necessary to
achieve and sustain gains in safety.
o Recommendation 3.1: Build a measurement and reporting infrastructure.
o Recommendation 3.2: Share data on safety in the home.
o Recommendation 3.3: Teach safety and improvement skills across the home health and
personal care fields and evaluate competency in these skills.
o Recommendation 3.4: Create an intensive improvement collaborative for early adopter
organizations.
o Recommendation 3.5: Create a learning system for identifying and sharing best practices
related to care in the home.
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Principle 4: Effective team-based care and care coordination are critical to
safety in the home setting.
o Recommendation 4.1: Create a common, longitudinal care plan based on the goals of the
care recipient or a care recipient/family caregiver dyad.
o Recommendation 4.2: Develop and test new models of team-based care.
o Recommendation 4.3: Ensure the visibility and use of community-based and
underutilized resources.
o Recommendation 4.4: Utilize technology to support team-based, coordinated care.
Principle 5: Policies and funding models must incentivize the provision of
high-quality, coordinated care in the home and avoid perpetuating care
fragmentation related to payment.
o Recommendation 5.1: Align payment models with the goals of whole-person,
community-based, coordinated care.
o Recommendation 5.2: Reduce the regulatory burden.
Increasing the reliability of the care system would be an important contribution to advancing the
safety of care in the home. As outlined in the IHI White Paper, A Framework for Safe, Reliable,
and Effective Care, increasing the reliability of the care system in ways that will move the needle
on safety in the home requires work in two foundational domains: the culture and the
learning system.2
Imagine what care at home would look like if best practices were widely adopted. Family
caregivers would be confident in the care they provide and would have access to support; those
who provide care, both family caregivers and home care workers, would be safe, healthy, capable,
and resilient; the home care workforce would care for the whole person rather than providing
only the specific services for which they are reimbursed; harm would be minimized; care would be
coordinated; and care recipients would receive safe, high-quality, coordinated care in the comfort
of their own home.
IHI recommends that every individual and organizational leader across the health care system
who is associated with care in the home — including clinicians, delivery organizations,
policymakers, and payers — come to a better understanding of both the potential harms in this
setting and effective mitigation strategies and take the necessary actions to improve the safety of
care recipients, family caregivers, and home care workers. This report describes these harms and
mitigation strategies. We hope that home care workers and leaders will read it carefully and share
it widely. This report will also be of interest to care recipients and family caregivers, because it can
provide them with an understanding of the safety issues that may arise in the home and help
them in decision making and advocating to reduce the risk of harm.
Safety in the home deserves the same level of attention to harm prevention, creation of a safety
culture, use of standard practices, and dedication of resources as we have given to other care
settings. This report is intended to convey a pressing call to action.
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Acknowledgments
IHI gratefully acknowledges Alice Bonner, PhD, RN, and Stephen E. Muething, MD, for their
work as co-chairs of this project; members of the expert panel for their participation; IHI staff for
project support; and Diane W. Shannon, MD, MPH, for lead authorship of this report.
We also acknowledge the use of the IHI report, Patient Safety in the Home: Assessment of Issues,
Challenges, and Opportunities, as background information for this work.
Expert Panel Co-Chairs
Alice Bonner, PhD, RN
Secretary
Massachusetts Executive Office of Elder Affairs
Stephen E. Muething, MD
Co-Director, James M. Anderson Center
Professor of Pediatrics, Michael and Suzette Fisher Family Chair for Safety
Cincinnati Children’s Hospital Medical Center
Expert Panel Participants
Mary Barton, MD, MPP
Vice President, Performance Measurement
NCQA
Deborah Carpenter, RN, MSN, CPHQ, PMP, CPPS
Senior Study Director
Westat
Michael R. Cohen, RPh, MS, ScD (Hon.), DPS (Hon.), FASHP
President
Institute for Safe Medication Practices
Ilene Corina
President/Patient Safety Advocate
Pulse Center for Patient Safety Education and Advocacy
Janet Corrigan, PhD, MBA
Chief Program Officer for Patient Care
Gordon and Betty Moore Foundation
Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM
Senior Director of Care Management
Stanley Shalom Zielony Institute for Nursing Excellence
Cleveland Clinic — Euclid Hospital, Medina Hospital, Akron Hospital
Rollin J. (Terry) Fairbanks, MD, MS, FACEP, CPPS
Assistant Vice President, Ambulatory Quality and Safety, MedStar Health
Co-Director, MedStar TeleHealth Innovation Center, MedStar Health
Founding Director, National Center for Human Factors in Healthcare
Professor of Emergency Medicine, Georgetown University
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Frank Federico, RPh
Vice President/Senior Safety Expert
Institute for Healthcare Improvement
Tejal Gandhi, MD, MPH, CPPS
Chief Clinical and Safety Officer
Institute for Healthcare Improvement
Teresa Harbour, RN, MBA, MHA
Program Director
Accreditation Commission for Health Care
Lisa Iezzoni, MD, MSc
Professor of Medicine, Harvard Medical School
Director, Mongan Institute Health Policy Center, Massachusetts General Hospital
Jennifer Kennedy, EdD, MA, BSN, RN, CHC
Senior Director, Regulatory and Quality
National Hospice and Palliative Care Organization
Ariella Lang, RN, PhD
Assistant Professor
McGill University Ingram School of Nursing
Andrew Lasher, MD
Chief Medical Officer
Aspire Health
Bruce Leff, MD
Professor of Medicine
Johns Hopkins University School of Medicine
Paul McGann, MD [*participated as an observer]
Chief Medical Officer for Quality Improvement
Quality Improvement Innovation Group
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services
Wayne Miller, MSc
Patient Safety Improvement Lead
Canadian Patient Safety Institute
Suzanne Mintz, MS
Founder
Family Caregiver Advocacy
Tracey Moorhead
Past President/CEO
Visiting Nurse Associations of America
Melissa O’Connor, PhD, MBA, RN
Associate Professor
Villanova University M. Louise Fitzpatrick College of Nursing
Leslie Pelton, MPA
Director, Innovation
Institute for Healthcare Improvement
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Margaret M. Quinn, ScD, CIH
Professor and Director
Safe Home Care Project
Department of Public Health
College of Health Sciences
University of Massachusetts–Lowell
Caroline Steinberg, MBA
Vice President, Programs
Network for Excellence in Health Innovation
Robyn Stone, DrPH
Senior Vice President for Research
LeadingAge
Matt Zavadsky, MS-HAS, NREMT
Chief Strategic Integration Officer
MedStar Mobile Healthcare
IHI Leadership and Staff
Caitlin Lorincz, MS, MA
Senior Project Manager
Patricia McGaffigan, RN, MS, CPPS
Vice President, Safety Programs
President, Certification Board for Professionals in Patient Safety
Patricia McTiernan, MS
Director, Program Communications
Katherine Rowbotham, MA
Project Manager
Diane W. Shannon, MD, MPH
Shannon Healthcare Communications, Inc.
Contracted Writer
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The Current State of Safety in the Home and a Future Vision: A Case Study
The Current State
Maria Lopez is an 89-year-old widow who lives alone and has mild cognitive impairment. Her
daughter lives two blocks away and tries to visit on weekends. However, she travels frequently for
work and is not always able to visit. Mrs. Lopez has a modest income, but her income is not low
enough for her to be eligible for Medicaid. She qualifies only for limited home services.
Mrs. Lopez’s advanced arthritis and heart failure make mobility difficult, and she also has
diabetes, which now requires daily insulin. She takes 12 medications each day, which the home
health agency puts out in a weekly reminder box. Owing to her poor vision, Mrs. Lopez receives
prefilled syringes from her local community pharmacy.
She receives home-delivered meals five days a week from her local council on aging, but she rarely
eats them because the food is unfamiliar to her (the dog enjoys them, however). Her family is
unaware that she is not eating well.
Mrs. Lopez misses her friends, most of whom have died or moved back to Puerto Rico. She spends
a lot of time alone, and she feels lonely.
Her primary care physician at the local community health center (CHC) is new to Mrs. Lopez; her
previous physician recently retired. At a routine visit, her blood pressure medication is increased
and she is given a referral to a neurologist to assess the worsening cognitive impairment. The
neurologist, noting her affect, adds an antidepressant medication and sends a note about the
change to her primary care physician, who does not receive it for several weeks.
One day Mrs. Lopez experiences dizziness getting up out of her chair, falls, and hits her head. Her
daughter arrives shortly afterward and, finding her mother on the floor, calls 911. In the
ambulance, Mrs. Lopez’s blood sugar is found to be 45. The emergency department (ED)
physician suggests that the family obtain more help at home or consider a nursing home. Mrs.
Lopez begs her daughter to take her home. The home care program adds two more hours per
week of in-home care.
A month later, Mrs. Lopez falls again, this time sustaining a hip fracture. After hospitalization,
she is transferred to a skilled nursing and rehabilitation facility for three weeks. Every day she
asks her family to take her home.
A Future Vision
Maria Lopez’s income is not low enough to make her eligible for Medicaid, but she is eligible for a
payment program for people approaching Medicaid eligibility (similar to the Washington State
waiver, the Massachusetts state home care program, and programs found in other states). Her
community has volunteer time banks through which volunteers provide companionship for
homebound individuals, addressing their loneliness, and assist them with instrumental activities
of daily living.
Culturally sensitive meals are delivered to Mrs. Lopez five days a week (as with some Meals on
Wheels programs today). Technology is used in several ways: to ensure proper medication
administration through talking medication reminders and to convey her pharmacist’s instructions
for the family, as well as through telemedicine, which enables her physician to watch Mrs. Lopez
self-administer insulin, and a unified pharmacy record that includes all of her medications,
regardless of where her prescriptions were filled.
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Mrs. Lopez was taking a total of 12 medications daily, but she now takes seven, after her primary
care provider at the CHC asked the pharmacist to review and stop any unnecessary medications.
She misses her friends, most of whom have died or moved back to Puerto Rico, but does not often
feel lonely because she is visited regularly by volunteers coordinated by age-friendly, livable
community programs. These programs receive some municipal and local aid as well as state and
federal funding.
One day Mrs. Lopez experiences dizziness getting up out of her chair. She falls and hits her head,
and her daughter arrives shortly afterward. Finding her mother on the floor, the daughter calls
911. In the ambulance, Mrs. Lopez’s blood sugar is found to be 45. The ED visit triggers a
comprehensive evaluation and risk assessment by the local community-based service
organization. The assessor recommends an integrated home care program, such as
Medicaid/Medicare’s Program of All-inclusive Care for the Elderly (PACE) program.
Her electronic health record is cloud-based, secure, and accessible to the entire care team,
including Mrs. Lopez herself, who can access the information in Spanish. The system can flag
potential drug interactions and polypharmacy (continued prescription of one or more drugs that
are not, or no longer, needed) and allows her care team to see the changes in her medication
made after the ED visit, including a reduction in her daily insulin dose. Community health
workers from the public health department conduct a fall risk assessment and develop a care
plan with Mrs. Lopez and her daughter. This information is accessible to the CHC and specialists.
Mrs. Lopez does not fall again.
The Imperative to Improve Home Care Safety
Since the release of the Institute of Medicine’s seminal report on medical errors in 1999, To Err Is
Human: Building a Safer Health System, patient safety in hospitals and other clinical settings
has received a great deal of attention.3 Various types of medical errors have been identified and
their prevalence estimated. Targeted interventions have been created to prevent these errors, and
some, such as catheter-related bloodstream infections, have been reduced.4–6 The same attention
has not yet been focused, however, on the safety of care provided in the home.
Today the home has become an important site of care for many people. Care in the home
comprises different services provided by a variety of individuals with a range of training and
expertise:
• Personal care services include assistance with bathing, eating, and shopping, and some
nonskilled basic health care, as well as help with other tasks. These services are provided by
personal care attendants (PCAs) or home care aides, who can be hired privately or through an
agency. Training requirements for PCAs are limited and licensure is not required.
• Home health care, which includes skilled nursing and medical or clinical services in the
home, such as skilled wound care, is provided by certified home health aides, visiting nurses
(registered nurses and licensed practical nurses), licensed social workers, physical therapists,
occupational therapists, and other professionals.
• Multidisciplinary teams deliver hospice care, or end-of-life care, which includes social worker
services, spiritual care, bereavement counseling, and volunteer services.
• Multidisciplinary teams also provide palliative care services to alleviate suffering for people at
any stage of disease.
• Mental or behavioral health services may be provided by a licensed social worker, behavioral
health specialist, mental health clinical nurse specialist, therapist, or psychologist.
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• Primary care services are sometimes provided in the home through specific programs.
Complex hospital-level medical or surgical services are sometimes provided in the home by a
skilled care team (e.g., through the perioperative surgical home model).
• Coordinated hospital-level services are sometimes provided in the home through formalized
programs, such as Hospital at Home. (See Appendix A for more information on this
exemplar program.)
• Emergency medical services (EMS), which are critical to transitions to more acute care
services, sometimes also provide coordinated care in the home through specific collaborative
programs. (See Appendix A for more information on exemplar EMS programs.)
In addition, although not often present in the home, physicians and pharmacists play critical roles
in the safety of care provided in the home. By directing and ordering care and serving as a
resource for medication management, respectively, physicians and pharmacists have a substantial
impact on home care safety.
Essential to all aspects of care in the home are family caregivers. These family members, friends,
neighbors, or volunteers coordinate services, provide the bulk of personal care services, and
support many aspects of home health, hospice, and palliative care services. They are an integral
part of the care team and the care recipient/family caregiver dyad.
The home health and personal care fields emerged in the early 1980s when Medicaid began
paying for services through waivers at the state level. The average hospital length of stay
subsequently declined from 6.5 days in the mid-1980s to 4.5 days in 2012.7–8 With the trend
toward shortened hospital stays, accompanied by a relative reduction in nursing home beds,
states expanded Medicaid home- and community-based services waiver programs to provide
continuing services for recent hospital patients. These programs cover personal care for eligible
individuals, with eligibility requirements varying by state. In addition, Medicaid-managed long-
term services and private insurers have begun covering an increasing volume and type of personal
care services.
Across the country, workers from home health agencies provide home health care services to
more than 3 million Medicare beneficiaries.9 As mentioned earlier, the US Department of Labor
reports that more than 2 million personal care attendants provided care in the home in 2016, and
that number is likely to grow by 40 percent by 2026.10
More and more people are seeking hospice services, or end-of-life care, and a majority of this care
is provided at home.11 More than 1 million Medicare beneficiaries were enrolled in hospice for at
least one day in 2015, collectively receiving more than 96 million days of hospice care that year.11
In addition, a substantial amount of care is provided by family caregivers. Approximately 43
million people provide unpaid care to an adult or child each year.12 It is worth noting, however,
that changing family and social dynamics have left many care recipients with no family or other
social support.
Many of us, including most care recipients and those who care for them, would agree that
there’s no place like home. Compared with inpatient settings, many benefits accrue from home
care, which:
• Preserves autonomy: Care recipients generally prefer to be at home and may have more
autonomy at home than in other care settings.13
• Is patient-centered: Home care workers can more readily identify and respond to the
preferences of the care recipient, especially regarding the balance of autonomy and harm.
• Maintains family and social ties: Remaining in the home may allow care recipients to better
maintain connections with family and friends.
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• Avoids complications: Care at home may reduce the risk of complications associated with
hospital and nursing home environments, such as infections, sleep disruption, and confusion.
• Enables home care workers to assess social determinants of health: Home care workers can
better understand and address social determinants of health in the care recipient’s home. For
example, they can more easily manage poor nutrition because they can readily see the
condition and amount of food available.
• Lowers costs for society: Providing care in an appropriate, yet less intense, setting may lower
overall costs for federal programs, such as Medicare and Medicaid, which are funded with
taxpayer dollars.14
Although there are many benefits of care in the home, it is not without its challenges — for both
care recipients and everyone who supports and cares for them. Existing data suggest that
preventable harm is an important issue in the home setting. Studies in the United States and
Canada have found that between 4 percent and 13 percent of home care recipients experience an
adverse event, the majority of which are falls, infections, mental health or behavioral problems, or
adverse drug events.15–17
Both home care workers and family caregivers may experience physical and emotional harm as
they provide care. Indeed, the health and safety of both care recipients and caregivers are strongly
interconnected. Family caregivers often find caring for a family member at home to be frightening
and overwhelming. They may also feel confused about how to navigate home care services and
anxious about making a mistake that could harm the person in their care. Other possible physical
or emotional harms to family caregivers include exposure to verbal abuse or violence, compassion
fatigue, and burnout.
Like family caregivers, home care workers can experience emotional harm — though in different
ways — from verbal abuse, physical and professional isolation from colleagues, and anxiety due to
difficult interactions with care recipients or family members.18 And like other health care
professionals, home care workers are at risk for burnout, especially given the long shifts, the
unpredictable environment of the home setting, and the isolation associated with working alone.19
The physical harms to which home care workers and family caregivers are vulnerable include
needlesticks and other injuries from sharps (sharp medical devices),20–24 back pain and
injuries,25–26 violence,25 and environmental hazards, such as exposure to the respiratory irritant
chemicals used for infection control.27 Additionally, some safety hazards found in home settings
are not present in institutional settings, such as the presence of smokers (care recipients and/or
family caregivers) on or near oxygen tanks, the reuse of needles for injections, and failure to safely
discard used needles. All of these hazards can pose serious threats to caregivers and care
recipients alike.21, 28
Care recipients and family caregivers need a reliable system of care and easy access to timely
resources. Family caregivers need effective training so that they can feel confident that they
are supporting the care recipient’s health and not causing harm. Care recipients who do not
have family caregivers need additional support and education to manage services and care
for themselves.
Similarly, home care workers need adequate training, ongoing monitoring, and ready access to
supervising professionals to provide guidance when needed. They require highly functional teams
with effective communication within which to work. In addition, home care workers need greater
awareness of and protection from the hazards within the home that can cause physical or
emotional harm.
More attention to safety is needed in an environment where an increasing amount of care is now
provided — the home. While a considerable amount of work has been completed in this area,
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especially in the home health and hospice and palliative care fields, safe care in the home setting
has generally received less attention nationally than safety in hospitals, nursing homes, and
ambulatory settings. We have yet to completely elucidate the nature and prevalence of risks in the
home and create optimal ways to improve safety in this setting. Given the increasing proportion
of care provided in the home, improving safety in this setting deserves urgent attention and
immediate action.
Safe Care in the Home: Definition of Terms
The variety of definitions used in the literature and in practice for terms related to care in the
home can make those terms unclear. What does the word “home” actually mean? Does it include
assisted living facilities and group home settings? What exactly is “home care”? Some groups use
that term to refer to personal care services only. Others define “home care” to include both
personal care and home health care. In discussing such variations in the terminology, the expert
panel identified the establishment of common definitions as an important early step in the
journey to optimizing safety in the home.
To ensure clarity in the terminology used to discuss safety in the home setting, the expert panel
recommended the following definitions. These definitions are not intended to replace those
developed by established groups, such as the World Health Organization or accrediting agencies.
Instead, they are offered here in the hope that clearly defined terms will contribute to a
productive conversation about safety in the home.
Two definitions, in particular, are fundamental. First, “home” is defined here as the place where a
care recipient lives. The expert panel’s narrow definition of home excludes care provided in
nursing homes, skilled nursing facilities, assisted living residences, and residential care settings,
because these settings have more paid staff and infrastructure than a private home. Second, “care
in the home” is defined as encompassing both personal care and home health care.
• Adverse event: Any injury caused by medical care. Identifying an injury as an adverse event
does not imply error, negligence, or poor-quality care, but simply indicates that some aspect
of diagnosis or therapy, not an underlying disease process, had an undesirable clinical
outcome.29
• Adverse drug event: An adverse event involving medication use.29
• Care recipient: An individual who is receiving care at home (term used in this report instead
of “patient”).
• Care recipient/family caregiver dyad: A term emphasizing the interrelated nature of the
safety of the care recipient and the family caregiver.
• Care recipient safety: The care recipient’s freedom from accidental or preventable harm
occurring in the home (e.g., a medication error in the home) or during the provision of
home care (e.g., an injury in a car accident caused by a personal care attendant driving
while impaired).
• Care in the home: Both personal care services and home health care provided in a home
setting.
• Error: An act of either commission (doing something wrong) or omission (failing to do
the right thing) that leads to an undesirable outcome or poses a significant threat of such
an outcome.29
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• Family caregiver: The person who cares for the care recipient in the home yet is not a
worker employed within the health care or home health care system. This person — who can
be a family member, friend, or community-based volunteer — is an integral part of the care
team and the care recipient/family caregiver dyad and often provides backup care for all
types of care provided in the home. In rare circumstances, family caregivers may be paid to
provide care.
• Harm: Impairment of the structure or function of the body and/or any deleterious effect
arising from such impairment. Harm includes disease, injury, suffering, disability, and
death30 and is now recognized to include both physical and emotional harm.31
• Home: The place where the care recipient lives (excluding group homes, nursing homes,
skilled nursing facilities, assisted living residences, and other residential care settings).
• Home care worker: An umbrella term for all who provide care in the home (with the
exception of family caregivers), including personal care attendants, certified home health
aides, visiting nurses (registered nurses and licensed practical nurses), licensed social
workers, physical therapists, and occupational therapists.
• Home health aide: A certified home care worker who provides health-related services, such
as medication management, and works under federal training requirements.
• Home health care: Skilled nursing and medical or clinical services provided in the home,
such as skilled medication management and skilled wound care. Federal regulations identify
six components of home health care: skilled nursing, home health aides, medical social
services, occupational therapy, physical therapy, and speech-language pathology.32
• Hospice care: End-of-life-care provided to terminally ill people and their families. Hospice
services include medical and nursing care, social worker services, spiritual care, bereavement
counseling, and volunteer services. This report uses the term specifically to refer to care
delivered by a hospice program.
• Hospital at Home®: A program in which a care team that includes professionals with specific
training provide hospital-level care in the home with the goal of avoiding hospitalization or
rehospitalization.
• Palliative care: Multidisciplinary services to alleviate suffering for people at any stage of
disease. This report specifically defines palliative care as services delivered through the
benefits provided by a health plan or other insurer, an accountable care organization, a state
home care program, or another entity.
• Personal care attendant (PCA): Sometimes referred to as a “personal care aide,” a PCA is a
home care worker who is hired either through a home care agency or directly by a care
recipient and whose primary responsibility is providing personal care services, such as
assistance with the activities of daily living, homemaking, meal preparation, and transport to
medical appointments. Training requirements are limited and licensure is not required,
although some PCAs have the certification required by nursing homes, such as that required
to work as a certified nursing assistant.
• Personal care services: Care that includes assistance with the activities of daily living
(eating, bathing, dressing, toileting, transferring, and continence) and may also include help
with the instrumental activities of daily living (e.g., shopping, homemaking, meal
preparation, and transportation) and help with basic health care (e.g., nonskilled medication
management). Personal care services are sometimes referred to as “long-term services
and supports.”
• Pressure injury: An ischemic injury to the skin and underlying tissues stemming from the
sheer force or friction of pressure on the body (also referred to as a “pressure ulcer”).33
• Primary care at home: Home-based primary care services provided by physicians, nurse
practitioners, and interdisciplinary care teams and operating under specific regulations.
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The Focus of This Report
This report details the feedback from the expert panel that IHI convened in November 2017
to consider the specific challenges to safety in the home setting and offer recommendations
for improvement.
To inform the two-day expert panel meeting, IHI enlisted a research organization to complete a
landscape analysis of the topic that included a literature review and feedback from semistructured
interviews conducted with subject matter experts: care recipients, family caregivers, health care
professionals, researchers, payers, and representatives from professional organizations,
government, and accreditation agencies. The results of this analysis are described in the IHI
report, Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities.34
The panel (and by extension this report) focused on the largest drivers of safety concerns, but the
conversation it began must expand eventually to include equally significant safety issues that
affect fewer people. For example, this report does not consider safety hazards that put people at
risk outside the home or clinical care setting, such as falling in the hospital parking lot before
gaining access to the facility, or being assaulted on the street outside the neighborhood pharmacy.
Although the report mentions some initiatives that provide a specific type of care in the home —
such as Hospital at Home — specialized programs are not its focus. (See Appendix A to learn
more about Hospital at Home and other exemplar programs.)
As noted earlier, the major focus of this report is safety related to two primary components of care
in the home: home health care and personal care. It considers the physical and emotional safety
of the care recipient, the family caregiver, and the home care worker, while recognizing the
interconnected nature of the safety of all these individuals.
The panel’s discussion was shaped by the ultimate goal of optimizing safe, person-centered care
for the unique environment of the home and creating a highly reliable system for delivering such
care. On the panel’s recommendations, the specific goals of this report include:
• Prioritizing key safety issues
• Identifying the effective tools and innovative strategies being used today
• Determining areas of focus and developing strategic recommendations that will have the
greatest impact on safety in the home
The Financing and Regulation of Care in the Home
Care in the home as currently provided is deeply shaped by its financing and the regulations by
which it is governed. Programs and services that provide care in the home are paid for and
regulated through different mechanisms, and one result is that care recipients may experience
inconsistent care coordination and gaps in services.
Financing
Home health care and personal care are paid for in a variety of ways by several different sources:
Home health care financing. The current payment options for home health care include
Medicare, Medicaid, the US Department of Veterans Affairs (VA), commercial insurance, and
self-pay. Many Americans have a misconception that governmental agencies fully cover services
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related to care in the home. However, coverage under governmental programs is available only for
short-term, medically necessary care; it is not available for long-term, ongoing services.
Medicare is the federal health insurance program for people who are age 65 or older and those
younger than 65 with a disability. Medicare covers health services in the home for eligible
beneficiaries who require a skilled service and have been certified as homebound by a physician.
Medicaid — a collaborative program between federal and state governments that covers health
care for low-income people of any age and children with special needs — pays for certain
qualifying home health services, although eligibility and benefits vary by state.
In recent years, the Centers for Medicare & Medicaid Services (CMS) has launched several
programs and demonstration projects aimed at containing the costs associated with home health
care and improving care quality. Value-based payment programs move away from fee-for-service
reimbursement and include incentives for care quality and safety. The move toward managed care
in Medicare Advantage plans and dual-eligible plans has increased the incentives for care
coordination and the potential for improved safety — through reduction of avoidable hospital
readmissions, for example. The impact of managed care on the safety of home care is
currently unknown.
In the past, Medicaid-managed care programs, such as CareSource, which was launched in Ohio,
have worked with community-based resources to support care in the home. Accountable care
organizations covering Medicaid recipients are now tasked with providing or finding this support.
If additional resources are provided through this payment model, it may be effective in increasing
safety in the home.
One important program launched by CMS is the Program of All-Inclusive Care for the Elderly (PACE),
which is available in 38 states. PACE provides primary care and home health services to individuals
who are eligible for both Medicare and Medicaid benefits and are clinically eligible for nursing home
admission in their state. (See Appendix A for more information about PACE.) Payment for PACE is
capitated and allows for more flexibility in selecting services, as the program is not limited to only
those services reimbursable under Medicare and Medicaid fee-for-service plans.
The Department of Veterans Affairs provides home health care services for eligible military
personnel, such as through the Veterans Affairs Home-Based Primary Care initiative. The
program is available to homebound veterans, as well as to those who are isolated or whose
caregiver is overburdened by their care. Although it provides some home health services, the
program’s primary goal is providing ongoing care in the home to veterans with functional
impairment who have significant difficulty with travel to the VA’s outpatient clinics. The VA also
offers the Veterans Independence Program which allows veterans in VA medical centers in 34
states, the District of Columbia, and Puerto Rico to access and self-direct home- and community-
based services.
In addition, many accountable care organizations and integrated health systems have home
health care programs in place.
Commercial insurance plans generally provide coverage for home health services that is similar to
that provided by Medicare, with payment for skilled, short-term, medically necessary care.
Separately, long-term care insurance is another option for covering services. Care recipients may
have the option to purchase long-term care insurance to supplement their medical coverage and
help finance potential long-term care expenses. Depending on the policy, home health care
services may also be covered. Long-term care policies reimburse insured individuals for a set
amount per day, up to a predetermined limit. However, the premiums are generally expensive
and the specific benefits vary by policy.35
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Finally, some states have programs to pay family caregivers to provide care in the home. Beyond
the benefits of such programs, families must provide care or pay for care out-of-pocket. However,
these services are costly and self-pay may be financially challenging for many individuals
and families.
For example, as the family member of a person needing care at home stated in an interview
conducted for the IHI report, Patient Safety in the Home: Assessment of Issues, Challenges, and
Opportunities: “In 2013, when my mom had a major fall, [suffering a] severely broken arm, she
was in our home recovering. We realized immediately, we desperately needed in-home care. We
had an organization calmly sit in our kitchen and tell us that would be $500 a day out of our
pocket, $500 a day for the care that she needed. We ended up having to put her in a rehab
facility, which in the end cost Medicare far more than if we had had the support to keep her in
our home.”34
Personal care financing. Medicare generally does not cover personal care.36 Medicaid may
cover some personal care services, which are referred to as home- and community-based services
(HCBS) when provided outside of nursing homes. HCBS are available to eligible individuals, but
eligibility and benefits vary by state, and many states maintain HCBS waiting lists. The VA offers
foster care or family care and other personal care services to eligible veterans. In some instances,
the VA reimburses family members for providing personal care services.
Self-pay for personal care services is common. Care recipients or family members can hire
personal care attendants either through agencies or privately. Finally, family caregivers provide a
large proportion of personal care services. Each year approximately 43 million adults in the US
provide unpaid care to an adult or a child.12
Today many middle-class care recipients and families cannot afford home care, including both
personal care and home health care services. More financially secure individuals and families may
be able to cover out-of-pocket costs, and very low-income people may be eligible for Medicaid
coverage. Socioeconomic status and ability to pay affect the care recipient’s choices and must be
recognized as important factors in access to appropriate, cost-effective care. In essence, the lack of
access to affordable care is in itself a safety issue. In addition, current payment models that cover
only specific services (e.g., fee-for-service payment) incentivize an approach that is narrow and
siloed rather than focused on the needs of the whole person — or the total cost of care.
Regulation
Regulation of care in the home varies based on the services provided. In the United States, no
single entity oversees all care in the home. In home health care, however, there are regulations
governing licensure, workplace conditions, and participation in federal and state payment
programs. In contrast, the field of personal care services is largely unregulated.
State licensure. Each state sets minimum standards for the licensure of home health agencies.
The standards, which vary by state, may include, for example, a required orientation class,
evidence of current commercial general liability insurance, and a description of the agency’s
organizational structure.37 Some states require licensure, others require a certificate of need, and
the remainder require both.38
In essence, the lack of access to affordable
care is in itself a safety issue.
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Workplace regulations. Home care agencies that employ home care workers must comply
with federal standards and regulations that are enforced by the Occupational Safety and Health
Administration (OSHA). Some of the relevant OSHA regulations include:
• A blood-borne pathogens standard, which requires that employees be trained about hazards
and record-keeping of needlesticks, sharps injuries, and blood exposure39
• A hazard communication standard, which requires businesses to inform employees about
known workplace hazards (chemicals, toxins, and blood-borne pathogens, for example) and
train employees in the safe handling of these hazards40
• OSHA Form 300 Log Book, which requires home care agencies to maintain records on
needlestick and sharps injuries41
In addition to these federal regulations, state regulations are in place that govern employee
training. These regulations vary widely by state.
It is important to note that privately hired, independent personal care attendants who are
not affiliated with a home care agency are not required to comply with these standards
and regulations.
Participation regulations. In the US, federal regulations govern the participation of home
health and hospice agencies as well as primary care providers in Medicare and Medicaid
programs and in demonstration projects, such as Hospital at Home. These standards are overseen
by the CMS central office, CMS regional offices, and state survey agencies. In January 2018, new
rules went into effect dictating the conditions of participation and designed to improve the quality
and safety of home health care.32
Accreditation. Besides federal and state governments, home health care is also governed by
accrediting bodies. For 2018, The Joint Commission issued five National Patient Safety Goals for
Home Care:42
• Correct patient identification
• Safe use of medications
• Infection prevention
• Falls prevention
• Identification of patient safety risks
The Home Health Certification Program, through which The Joint Commission certifies home
health agencies, hospice providers, personal care agencies, and others, is based on these goals.
The Accreditation Commission for Health Care (ACHC) has also established standards for home
health and hospice services provided in the home. These include:
• HH5-2C: A comprehensive assessment of the care recipient’s environment and identification
of safety and health hazards, including the adequacy of the living arrangements, the safety of
the home, and emergency preparedness
• HH6-1A: The Quality Assessment and Performance Improvement (QAPI) program focuses on
indicators related to the use of emergent care services, hospital admissions and readmissions,
and the prevention and reduction of medical errors
• HH6-5A: Performance activities that identify issues that directly or potentially threaten the
health and safety of care recipients
• HH7-1A: Education for both the care recipient and the caregiver on infection prevention and
control issues
• HH7-2B.01: The established policies and procedures addressing safety in the home for care
recipients, including measures to monitor the care recipient’s medication compliance, the
safety of the care recipient’s medical equipment, and basic home safety measures43
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Challenges Unique to Safe Care in the Home Setting
Providing safe care in the home setting is challenging for several reasons that differ from the
safety issues in hospitals, nursing homes, or ambulatory settings. Care in the home is very
complex because it brings up issues of physical space, socioeconomic differences, isolation, and
the balance of respect for autonomy and prevention of harm.
Care in the home is provided outside the controlled environment of the health care
system. One of the most important differences between care provided within the health care
system and care provided at home is the environment in which care is delivered. While health
care system settings are strictly regulated for safety, including environmental factors such as
sanitation, equipment, and infection control, the home is not. The physical layout of the home
may present constraints that are not present in the hospital setting, such as several sets of stairs.
And unlike hospital staff, some individuals who provide care in the home may have limited
training.
The home environment also highlights the multidimensionality of safety. Safety encompasses
more than mitigating the risk of physical harm. It also requires attention to potential emotional,
social, and financial risks. Feedback from people receiving care in the home and family members
illustrates the importance of a holistic approach.34 In the home setting, the consequences of harm
across the range of parameters — physical, emotional, social, functional, and financial — are very
apparent, and maintaining a whole-person perspective is especially important. In addition,
experienced safety and quality professionals, practices, and measures may not be available in the
home setting for accelerating focus and improvement in safety, as they are in most hospitals.
For anyone receiving care in the home, safety should be a priority, not an add-on or afterthought.
Safety needs to be taken into account not only at every individual care encounter, but also in the
design of the technology to be used in the home, in the creation of communication tools, in the
training of care recipients, family caregivers, and care workers, and in monitoring and other
aspects of care.
Important safety-related questions to consider include:
• In which circumstances is the home the best setting for providing the safest and the most
effective and efficient care?
• What is the optimal way to balance delivering more care at home, to avoid more intensive
treatment settings, while preserving the sanctuary of the home and the autonomy of the
care recipient?
• Are family caregivers available and capable of providing the level of care needed?
Communication and care coordination can be more difficult in the home setting. Although
ineffective communication and poor care coordination are common safety issues across the health
care system, the physical separation of the home setting makes effective communication and
optimal care coordination an even greater challenge. Care provided in the home comes from
many sources and may take place in geographically diverse locations. Also, care in the home
involves a large number of handoffs — among the different professionals providing care (located
within and outside the home) and between the care team and the care recipient/family caregiver
dyad. Each handoff represents an opportunity for effective communication and care coordination
— or for lapses that introduce the risk of harm. Best practices for communication in the hospital,
such as SBAR (Situation, Background, Assessment, Recommendation) and standardized
handoffs, are often not applied in the home, not even in adapted form.
Many home health agencies are highly adept at sharing information across the care team and
connecting care recipients and family caregivers with community resources. However, in other
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cases, information vital to optimal care in the home setting is not well disseminated. In addition,
care recipients and family caregivers often do not receive upfront training about the tasks that
they will be undertaking and timely information about resources to address subsequent questions
and concerns.
Different care workers in the home have varying areas of expertise and different priorities. Some
may focus only on their own tasks, in part because of the incentives in many payment models,
which reimburse for specific services for specific diagnoses, rather than for whole-person care. As
one family member noted, “A nurse can come in from one agency. A physiotherapist might be in
from another agency. A personal support worker could be there all the time from a different
agency. And none of them talk to one another.”34
Gaps in care coordination are especially evident at care transitions. Poor communication and
inadequate transfer of information, lack of education for care recipients and family caregivers,
and lack of understanding of the home environment and the implications for care increase the
risk of harm when the care recipient’s site of care or source of care changes. In addition, needed
supplies, such as dressings and colostomy bags, may not be readily available when care recipients
transition to their homes. Too often, care recipients or family caregivers must fill the vacuum in
care coordination and find themselves reporting test results and clinical recommendations to
various members of the care team.
In addition, clinicians, such as emergency department staff and primary care physicians, are often
unaware of community-based resources and networks that could be leveraged to assist with care
in the home setting. Even clinicians who are aware of community support organizations may not
consider whether the care recipient needs assistance in interfacing with these resources. For
example, as one expert panel member noted, a frail older person living alone may need “more
than an 800 number on a slip of paper” to coordinate transportation.
Finally, existing resources that could be leveraged to improve care coordination and efficiency are
underutilized. For example, the emergency medical services (EMS) personnel who respond to
calls for assistance in people’s homes are critical to transitions to more acute care services. In
some areas of the country, innovative programs have been implemented that enlist EMS
personnel to provide and coordinate care. One study found that an integrated program utilizing
EMS personnel to provide care for people who frequently use the ED for conditions that could be
treated in the primary care setting reduced ED usage and increased quality of life.44 (For more
information on exemplar EMS programs, see Appendix A.)
Safe care in the home requires balancing autonomy and risk. The home should be a place
controlled by the care recipient and not, as in other care settings, by the provider of care. In the
home setting, the care recipient is more likely to be autonomous and better able to make choices.
Self-determination includes people’s right to make their own decisions and put themselves at risk
if other factors are more important. Care workers’ desire to mitigate potential risks and care
recipients’ desire for autonomy may come into conflict. For instance, a throw rug may be an
object of personal importance, not simply a tripping hazard. Reducing the risk of falls must be
balanced with respect for the agency and rights of the person receiving care.
Home care workers must clearly explain the risks and benefits of activities intended to prevent
harm, giving care recipients who are capable of making their own decisions the opportunity to
make informed choices. Understanding the values and preferences of the care recipient is
essential to preventing unintentional harm related to the presence of a care worker in the home.
Failure to respect self-determination may stem in part from the historical paternalism of our
health system, but also from the concerns of those who provide care in the home about protecting
themselves legally if harms occur.
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In addition, it may be challenging to balance the safety concerns of family caregivers with those of
the care recipient. For example, family members may want complete control over their loved
one’s actions and care, but the care recipient may desire greater autonomy. The importance of
balancing autonomy and harm and what matters most to the individual receiving care must be
discussed with family caregivers as well.
The care recipient and the people providing care are often closely linked. A home with
safety hazards endangers both the person receiving care and the people providing it. Hazards
such as sharps, clutter, unsanitary conditions, and verbal or physical abuse by family members or
care recipients can affect the safety of everyone in the home.
In addition, family caregivers without adequate support or training may develop health problems
themselves, such as back pain from lifting the care recipient. It is important to view the care
recipient and family caregiver as a single unit of care because the two function as a dyad. As one
family member described it, “Family caregivers and the person they’re caring for are intertwined
like a double helix. We’re completely intertwined, so what happens to me happens to [spouse],
and what happens to [spouse] happens to me.”34 Mitigating risk must take into account both the
care recipient and the person providing care.
The health literacy of those in the home is often limited. Health literacy is “the degree to
which individuals have the capacity to obtain, process, and understand basic health information
and services needed to make appropriate health decisions.”45 Research has demonstrated that
most adults have difficulty understanding information about health care.46–48 Depending on how
health-literate they are, many care recipients and family caregivers may be confused about how to
use medications safely or adhere to a care plan.46-47 Failure to acknowledge and adapt messages
for audiences with low health literacy skills can reduce the effectiveness of communication
and training.
Available data measuring safety in the home are highly variable. One of the most glaring
deficiencies related to care in the home is the failure to use a common system for measuring
safety in this setting. True advancement in safety in the home setting will require standard
measures that can be used by all who provide care and that remain relevant across a variety of
home settings. The use of standard measures would allow for systematic data collection, which is
critical to understanding the magnitude of safety issues in the home. At present, there are no
national or state requirements for reporting safety issues in the home, and only pockets of data
are available for care provided in the home. Home health agencies have developed common
measures of safety, and data related to home care workers are captured in the Outcome and
Assessment Information Set (OASIS). Home health agencies must report on OASIS data as a
condition of participation in Medicare.
However, these data may not be easily accessible to others working in the health care system,
such as emergency department staff evaluating a person who has received care at home. In
addition, many care recipients do not have home care workers collecting their data, and data on
care provided by family caregivers is often not captured systematically. Thus, much of what
occurs in the home is not visible across the health care system. Collection of such data remains a
key challenge to improvement.
There is a need for research in many aspects of safety in the home, including:34
• Standardizing operational definitions and taxonomy
• Developing and testing home-based safety measures
• Understanding family caregivers’ and home care workers’ characteristics, abilities, and needs
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• Assessing technology for effectiveness and safety, including consistency with human
factors principles
• Developing and testing standard, comprehensive, person-centered processes that assess
the care, the family caregiver, and the environment
• Identifying and testing models of care delivery and financing
• Assessing the safety, health, and well-being of home care workers and implementing
preventive interventions to benefit both the home care worker and the care recipient
The home setting is often socially and physically isolated. The home may be a more isolated
environment than other care settings. Home care workers often work alone, with little access to
peers and direct supervisors for immediate support. Similarly, care recipients and family
caregivers may struggle with isolation and find that their ability to engage in social activities is
restricted. Feeling that others do not fully understand their situation, they may withdraw socially.
Family caregivers who are unable to leave their care recipient may become isolated if they cannot
find respite care. In addition, some care recipients and family caregivers may experience more
physical distance from those providing care within the health care system.
Home settings encompass a variety of needs and populations. Although a majority of care
recipients in the home are older adults (who will make up an increasing proportion of home care
recipients with the aging of the US population), it is important to recognize the variety of people
receiving care in their homes. Care recipients include adults, adolescents, and children as well as
people with short-term and long-term care needs, including:
• Frail older adults
• Older adults with multiple comorbid conditions
• Adults and children with cognitive impairment or dementia
• Adults and children with chronic illness, or physical, mental, behavioral, or
intellectual disabilities
• Adults and children receiving palliative or end-of-life care
• Adults and children who are otherwise healthy and receiving acute postsurgical
services, such as rehabilitation after joint replacement surgery
• Adults and children living in rural communities and those living in inner cities
• Low-income adults or families
These populations have very different needs. For example, older adults may have diminished
cognitive function and be increasingly dependent on their family caregiver. People with
disabilities who are young and cognitively healthy may need to assert their independence. The
vast variety of needs among the various populations receiving care in the home makes
appropriate standardization of practices and safety a challenge. In addition, culture and language
differences between the care recipient and home care workers can introduce bias, racism, and
language barriers into the provision of care.
Because of the specific challenges to providing safe care in the home, safety interventions used in
other settings cannot simply be applied to the home. Understanding the type and scope of the
risks specific to care in the home is essential to identifying effective strategies for mitigating those
risks and optimizing the well-being of people who receive care in their homes.
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Key Types of Harm in the Home Setting
Although there are many types of potential harms in the home setting, the expert panel focused
on those that affect the greatest number of people. The November 2017 panel discussion
emphasized the interrelated nature of these harms and their underlying causes. For example,
medications may raise the risk of falling by inducing dizziness or unsteady gait. That risk is
increased in a home that has not been adapted for safety in care — for example, scatter rugs have
not been removed, or grab bars have not been installed. Acknowledging the impact and interplay
of these harms can help inform effective prevention strategies.
Types of Harm in the Home
• Adverse events related to medication and other forms of treatment
• Injuries due to physical hazards in the home
• Injuries related to equipment and technology
• Pressure injuries
• Infections
• Conditions related to poor nutrition
• Adverse effects on family caregivers
• Adverse effects on home care workers
• Potential abuse and neglect of care recipients
Adverse events related to medication and other forms of treatment. Medication errors and
other problems with medication use represent a significant source of harm for people receiving
care in the home. It is estimated that about 40 percent of recipients of home health care
experience a medication error or other drug therapy problem.49 In addition, the risks associated
with medication use in the home affect care recipients across all subgroups. Inappropriate
polypharmacy and the use of inappropriate medications have been identified as two of the
primary underlying causes of medication-related harm in the home.50–51 Other issues include
improper dosing; confusion about medication orders and names; poor medication adherence due
to economic, access, or social factors; unsafe storage; and improper disposal.34 Drug misuse and
abuse, accidental ingestion by children, drug diversion, and poorly labeled packaging are other
potential problems. (See Appendix B for the expert panel’s suggested tactics for advancing
medication safety.)
Adverse events related to other forms of treatment are also important types of harms that occur
in the home setting. Dialysis, wound care, central line changing and maintenance, and other
treatments in the home introduce the risk of infection, poor healing, and other injuries.
Injuries due to physical hazards in the home. Both the person receiving care and those
providing it are at risk for injury due to physical hazards present in the home, such as clutter,
tripping hazards, expired food items, faulty equipment, and potential needlesticks and sharps
injuries. Falls — a growing safety risk in the home, especially for older people — are now the
leading cause of accidental injury and death among older adults.52–53 Approximately 30 percent
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of adults age 65 and older fall each year, resulting in about 29 million falls.53 About one in four
of these falls require medical treatment or restricted activity for at least one day. Direct costs
related to fatal and nonfatal falls in 2015 were $637.5 million and $31.3 billion, respectively.54 In
addition, older adults who experience a fall may restrict their activity because they are fearful of
falling again, but restricted activity can contribute to subsequent physical deconditioning.55
There are many reasons why people fall, including issues with gait and balance, clutter in the
home, medication side effects, poor nutrition, dehydration or other acute illness, cognitive
impairment, poor vision, and the effects of existing health conditions. Falls can also be caused by
physical limitations due to poor conditioning or progression of disease, particularly at the end of
life. In addition, substance use — for example, alcohol or misused prescription drugs, such as
opioids or benzodiazepines — can be a factor.
Fall prevention begins with recognition of risk, yet research has shown that fall risk assessments
are not routinely conducted.56 Fall prevention can be challenging in that the risk may not be fully
appreciated until after a fall has occurred. In addition, to assert their independence, care
recipients may avoid the use of assistive devices and resist or refuse other adaptations to the
home environment (such as reducing clutter).
The detrimental effects of clutter extend beyond raising the risk of falls. As one clinician
recounted in an interview, “I had a patient who had sores due to extreme swelling in her feet.
When I finally entered the home to provide her care I found out that her house was so dirty and
cluttered she did not even have a place to lay down to put her feet up… There was two to four feet
of garbage everywhere in her apartment.”34
Although outside the scope of this report, other physical hazards may arise from neighborhood
crime, which can impact both the care recipient/family caregiver dyad and the home care worker.
For instance, the presence in the home of medications that are commonly “diverted,” such as
prescription opioids, may increase the risk of theft and associated violence.
Injuries related to equipment and technology. Technology, such as wearable sensing devices,
telemedicine, Internet-based education programs, and automatic medication dispensing systems,
can extend the time that patients are able to reside safely at home and help them maintain a sense
of security in the home. However, health care–related equipment present in the home can also
heighten the risk of harm for the care recipient, family caregivers, and home care workers if it
is used improperly, if it adds to clutter or becomes a tripping hazard, and if it introduces
alarm fatigue.
Safety challenges related to technology include insufficient training of the care recipient and
family caregivers in technology use, lack of confidence in ability to use the technology, off-label
uses of technology, sometimes high out-of-pocket costs, lack of technical support, lack of
user-centered design, poor assessment of home readiness, and lack of data about errors and
equipment malfunctions.
As one researcher commented, “Any device that’s being deployed in a hospital these days, you’ll
see them at home as well: infusion pumps, ventilators, and different kinds of assistance
devices… but you don’t have someone who can necessarily fix them if they break, or figure out if
there’s a problem. There’s a potential of a safety issue if a device malfunctions. It may not be
recognized.”34
The proper use of equipment requires training, servicing, and upkeep, which can overburden the
care recipient or family caregivers. Inappropriate, broken, or poorly fitting equipment, such as
mobility aids, can also introduce risk. In addition, an insufficient stock of supplies in the home
due to inadequate communication, planning, or inventory management, or other supply issues,
can introduce barriers to safe care.
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The use in the home of complex devices such as ventilators, infusion devices, and dialysis
machines introduces risks that generally do not arise in more closely monitored settings. For
example, care recipients or family caregivers must be trained to understand and appropriately
respond to alarms, to maintain a hygienic or sterile environment, and to identify and replace
malfunctioning equipment. Some care recipients and family caregivers may become very
comfortable, even expert, in the use and maintenance of devices used in the home, but others
may find these tasks overwhelming.
The trend toward providing care in the home via telemedicine, remote monitoring, home hospital
programs, or home dialysis raises safety issues in the home to a new level. Continued research is
needed to determine the best type of care that is warranted.
Pressure injuries. Pressure injuries, or pressure ulcers, are ischemic injuries to the skin and
underlying tissues caused by the pressure of sheer force or friction on the body.33 Because a
primary risk factor for pressure injuries is prolonged pressure,33 they are a serious concern for
care recipients with restricted mobility. The reported incidence ranges from 0 to 17 percent of
home health agency clients, compared with 0.4 to 38 percent of patients in hospitals, according to
the National Pressure Ulcer Advisory Panel.57 Research suggests that prevention strategies in the
inpatient setting need to be adapted for use in the home, such as repositioning and adequate
nutrition.58 Economic and social resources should also be taken into account — for example, the
care recipient’s financial resources and the availability of support inside the home.59
Infections. The lack of a controlled environment in the home introduces challenges related to
infection prevention. As a member of a health-related association stated in an interview, “Being
trained in the hospital is being trained in a safe environment. Oftentimes, the questions that
patients have about a certain procedure don’t become apparent until they’re in the home. ‘Is the
dog allowed to jump on the bed when I do this wound care?’ It’s the uncontrolled environment
that makes training in the home really important.”34
Care recipients and family caregivers are often called upon to prevent or treat infections, but they
may be inadequately trained for these tasks or may not know when to seek help. They may be
unaware of the importance of handwashing and personal hygiene to infection prevention and may
not know how to recognize infections early in their course. Care recipients and family caregivers
also may not know how to avoid harms related to infection control prevention — such as avoiding
the use of products that contain bleach and other strong chemicals that are respiratory irritants
and can trigger chronic obstructive pulmonary disease and asthma events in both care recipients
and caregivers.
Conditions related to poor nutrition. Compromised nutrition is both a health and a safety issue.
In the inpatient setting, the acute nutritional needs of patients can be addressed by ordering a
customized dietary plan. In the home setting, by contrast, lack of access to safe, adequate food
may increase the risk of harm. Barriers to adequate nutritional resources include limited financial
resources, difficulty with food preparation, lack of transportation to purchase food, or a residence
located in a “food desert” (i.e., a community with little access to fresh meats, dairy, and produce).
While poor nutrition is not an exclusive function of a home setting, a poor nutritional state or lack
of fluid intake can lead to dehydration, electrolyte imbalance, poor healing for pressure ulcers,
and the potential for falls and other injuries.
“Oftentimes, the questions that patients have about a certain
procedure don’t become apparent until they’re in the home.
‘Is the dog allowed to jump on the bed when I do this wound care?’”
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Other potential nutrition-related concerns in the home setting may stem from safety issues
related to tube feedings, the use of infusion devices, and the care of gastrostomies and
jejunostomies. Safety issues can also arise when the food supply in the home is unsafe because of
expired use-by dates, spoilage, or poor storage practices. A key issue in nutrition safety is
inadequate communication about nutrition and the status of the food supply in the home at
handoffs and transitions from other care settings to the home.
The presence of care workers in the home opens a window onto the type and amount of food
available for the care recipient and provides an opportunity to focus on improved nutrition as an
important driver of health.
Adverse effects on family caregivers. Care provided in the home has become increasingly
complex, and family caregivers are often asked to take on complicated aspects of care, such as:
• Supporting activities of daily living, which may include heavy physical work such as lifting
or transferring the care recipient
• Medication management
• Wound care
• Scheduling and coordinating services
• Training other family members to provide care
• Addressing mental, behavioral, or cognitive conditions, including physical and emotional
manifestations of distress
Perhaps most notably, half of all family caregivers perform skilled care and three-fourths manage
medications, including those administered via intravenous lines, injections, and infusions.60 This
level of care may prove to be physically and mentally overwhelming for some family caregivers.
A noteworthy sign of progress is legislation that has now been either introduced or already passed
in several states called the Caregiver Advise Record and Enable (CARE) Act, which requires that
hospitals provide support to the family caregiver by recording his or her name in the medical
record, telling the caregiver when the care recipient will be discharged, and providing instruction
on any medical tasks the caregiver will need to perform at home.61 The legislation seeks to address
a gap in communication and education that has too often left family caregivers without the
information they need to provide care safely and confidently at home.
Family caregivers are at risk for caregiver burnout and compassion fatigue due to the stress of
caring for a loved one. Caregiver burnout manifests in physical symptoms such as weight loss or
gain and sleep disturbances.62 Compassion fatigue is suspected when a caregiver comes to feel
hopeless, indifferent, pessimistic, and generally uninterested in other people’s issues.63
Limitations of time, energy, and financial means may prevent family caregivers from attending to
their own health, and such neglect can cause them to develop significant health conditions
themselves. The mortality rate of family caregivers who experience mental or emotional strain
from caregiving is 63 percent higher than it is for a matched control group.64 A family member
explained in an interview, “I am now a senior myself, but I shoulder the entire household
responsibility, from cooking, cleaning, and shopping to mowing the lawn and shoveling the snow.
I am overworked and worn out.”8
Family caregivers may feel overwhelmed or saddened by the circumstances that have made care a
necessity, and burnout or inadequate support may make them “second victims” of adverse events
that occur during their time as caregivers. One clinician described such a situation: “This man — a
tough guy — was crying his eyes out. He was saying, ‘I can’t imagine that I’m the one who hurt my
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own mother. How can this happen? How can they make me do this to her?’”34 This emotional
burden is also particularly difficult for parents caring for their children with chronic conditions.
Family caregivers may feel isolated and overwhelmed, especially if inadequately trained and
psychologically unprepared for their caregiving tasks. An index has been developed to assess
family caregivers’ experience of burden from caring for a care recipient based on the number of
hours of care provided and the number of activities of daily living and instrumental activities of
daily living performed.12 Research has shown that about 40 percent of family caregivers
experience a high level of burden and that the same percentage report a high level of stress.12
Specific programs to assess the needs of family caregivers in the home are being piloted in a
number of states. A family caregiver support program in Washington State has been shown to
reduce depression, relieve the stress burden, and decrease the possibility that the caregiver will
place the care recipient in a nursing home.65
Adverse effects on home care workers. Home care workers are also at risk for emotional and
physical harm, although these often differ from those affecting family caregivers. Factors that may
lead to safety issues for this workforce include low pay, lack of benefits, limited training, and
language or cultural differences. In addition, home care workers may be harmed by physical
hazards in the home or by verbal and physical abuse by patients and family. A key challenge in
advancing safety in the home is balancing the well-being and preferences of the care recipient
with the safety of the home care worker. For example, the risk of harm to the home care worker
may sometimes be unacceptably high — such as when a care recipient smokes while on oxygen.
Health care workers in general have a relatively high injury rate, and that risk extends to home
care workers. For example, home health aides employed by agencies have a reported incidence
rate of 15.3 nonfatal illnesses and injuries per 100 workers, compared with 3.9 per 100 workers
employed in the health care private sector, such as physician’s offices.1, 66 As one home health aide
stated, “I have a client that is on oxygen and she smokes while she has it on… she doesn’t want to
stop. She has had social workers, nurses, everybody you can think of going in there to tell her to
stop. I actually see sparks on her nose.”67
Like family caregivers, home care workers may feel isolated and overwhelmed in their work. In
addition, home care workers are sometimes not given adequate tools or supervision to complete
their work effectively and efficiently. For example, some home care agencies continue to use
paper-based recording systems, which make it difficult to communicate across the care team and
to collect and assess data related to care in the home.
Potential neglect and abuse of care recipients. Care in the home may sometimes lead to —
or make evident — the neglect, abuse, or financial exploitation of care recipients, including
those who are especially susceptible, such as older adults, people with physical or intellectual
disabilities, and children. It is estimated that, overall, one in ten elderly people are victims
of abuse.68
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The Existing Foundation for Care in the
Home
Advancing safety in the home is an issue with a strong foundation. Home health care and
hospice and palliative care are two of the many fields that have built this foundation over the
past several decades.
Considerable work has been done to develop a reporting structure, a safety culture, and safe
practices in home health care. In particular, this field has amassed a substantial body of research
and data on safety through OASIS, a database that was launched in 1999 and is used for research
and policy-setting.69 Upon hospital admission, discharge, transfer, and change in condition, all
Medicare patients receiving home health care are assessed by professional registered nurses using
this standardized tool. When physical, occupational, or speech therapists are involved, they
coordinate with the registered nurse to complete the OASIS assessment. This tool forms a
universal body of information about patients that tracks changes and progress over time, and the
resulting database is a public resource that can be used for research and public reporting.
Components of the OASIS tool that are considered key to the quality and safety of care in the
home are combined with responses to the Home Health Care Consumer Assessment of
Healthcare Provider and Systems survey and then shared transparently with the public through
the Medicare Home Health Compare website. Other examples of the focus on home health care
safety are reflected in the national Home Health Quality Improvement campaign. Sponsored by
CMS, this campaign by the nonprofit organization Quality Insights is a collaborative effort to
develop resources and education for home-based care professionals.
In addition, numerous private groups and coalitions work across the country on safety in the
home setting. One example is the Stop Sepsis at Home project. The Home Care Association of
New York led a statewide, multistakeholder effort funded by the New York Health Foundation to
develop a novel in-home screening tool for sepsis, complete with a full program of educational
opportunities to support implementation. This effort demonstrates the impact of home health
care leadership on safety.
Separately, the hospice and palliative care fields offer a holistic model of coordinated,
interdisciplinary care in the home in a person- and family-centered manner. Hospice provides
end-of-life care and support services to people with a terminal illness and their families. Hospice
programs effectively coordinate skilled nursing, social worker services, spiritual care,
bereavement counseling, and volunteer services and demonstrate best practices for delivering
whole-person and family-focused care. Palliative care comprises multidisciplinary services to
alleviate suffering for people at any stage of disease. Included in the Affordable Care Act was a
provision for the establishment of the Hospice Quality Reporting Program for hospice providers.
Data on hospice quality and safety are routinely collected and shared via the Medicare website
Hospice Compare.
Previous work in the home health and hospice and palliative care fields provides a foundation on
which to build. Going forward, efforts must be made to spread these achievements across all
forms of care provided in the home.
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Guiding Principles
In discussions during and after the expert panel meeting in November 2017, several overarching
principles emerged that are foundational to improving the safety of care in the home regardless of
the population, type of home environment, or clinical situation. The expert panel firmly believes
that these principles should guide every interaction, every discussion, every decision, every care
plan, and all aspects of training and education.
1) Self-determination and person-centered care are fundamental to all
aspects of care in the home setting.
Respect for the sacredness of the home is essential to maintaining dignity. People receiving
care at home may not see themselves as “patients.” For example, people with physical
disabilities who receive care at home are not ill. With this in mind, home care workers must
avoid “medicalizing” the home environment.
Care provided in the home must balance the need to respect the care recipient’s right of self-
determination and autonomy with mitigation of the risk of harm. Family caregivers and home
care workers must acknowledge that it is impossible to mitigate all risks in the home setting
and that self-determination and the care recipient’s values must be respected in any attempts
to improve safety. All aspects of care, and especially care plans, must incorporate the values of
the care recipient and family caregivers. In addition, some safety experts suggest that
incorporating the concept of dignity into safety work can help prevent unintended
consequences.70 Respecting and upholding self-determination is an important component of
person-centered care.
Person-centered care in the home must be focused on the care recipient and family members
and is especially critical in the home setting — safety in the home cannot advance without it.
Person-centered care is one aspect of people-centered care, which “is broader than patient-
and person-centred care” and is defined by the World Health Organization as:
“…an approach to care that consciously adopts individuals’, carers’, families’ and
communities’ perspectives as participants in, and beneficiaries of, trusted health
systems that are organized around the comprehensive needs of people rather
than individual diseases, and respects social preferences. People-centred care
also requires that patients have the education and support they need to make
decisions and participate in their own care and that carers are able to attain
maximal function within a supportive working environment. People-centred care
…encompass[es] not only clinical encounters, but also includes attention to the
health of people in their communities and their crucial role in shaping health
policy and health service.”71
It is important, however, to recognize the inherent tension between supporting self-
determination and viewing the care recipient/family caregiver dyad as intricately
intermeshed. The care recipient’s goals and preferences must be determined first (unless he
or she does not have decision-making capacity), and then the conjoined needs of the care
recipient and family caregiver must be addressed in concert.
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2) Every organization providing care in the home must create and maintain
a safety culture.
An important aspect of improving the safety of care in the home is increasing the reliability of
the care system. The IHI White Paper, A Framework for Safe, Reliable, and Effective Care,
discusses the need for work in this realm to take place in two equally important foundational
domains: the culture and the learning system.2
Increasing the safety of care in the home requires more than simply collecting prevention
strategies and interventions. It requires an overarching commitment to safety. How can we
create a culture of safety in the home setting? We can start by recognizing what a culture of
safety looks like in the health care system.
As described in 2005, “In a safe culture employees are guided by an organization-wide
commitment to safety in which each member upholds their own safety norms and those of
their co-workers.”72 A definition more relevant to the home setting might be: “In a safe
culture, care recipients, family caregivers, home care workers, and other personnel who
support care in the home are guided by a person- and family-centered commitment to safety
in which each person upholds their own safety norms and those of the others in the extended
care team.” The goal is for safety to be a property of the system of care in the home, rather
than an afterthought.
Both the culture of safety and the specific safety practices need to be inclusive, attending to
the safety of care recipients and everyone who provides care. Indeed, caring for the family
caregiver and home care worker is just as critical to safety as caring for the care recipient.
As previously discussed, people who provide care in the home are at risk for experiencing
emotional or physical harm as they go about their work. In addition, the home setting harbors
risks not generally seen in the health care system, such as isolation. Evidence suggests that
health care organizations that focus attention on workforce safety simultaneously improve
patient safety.73
To significantly improve the safety of care in the home, safety culture and practices need to
inform every action and decision associated with that care. For instance, in the hospital
setting, safety culture surveys are routinely conducted to assess practices and improve safety.
Such surveys should be routinely adapted for use in the home setting as well. Otherwise,
safety may come to be considered an “add-on” — one more item on the list of services
provided by a home care agency or an individual home care worker — rather than being fully
integrated into the practice of care.
In a safe culture, care recipients, family caregivers, home care workers,
and other personnel who support care in the home are guided by a
person- and family-centered commitment to safety in which each person
upholds their own safety norms and those of the others in the extended care team.
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3) A robust learning and improvement system is necessary to achieve and
sustain gains in safety.
A learning system includes leadership (also a component of culture), transparency, reliability,
improvement and measurement, and continuous learning.2 Developing this is essential to
improving the safety of care in the home setting.
However, safety practices and techniques that are effective in the hospital setting are not
necessarily useful in the home. Individuals and organizations must develop or identify
effective strategies to improve safety in the home, and to accelerate change they must quickly
share these strategies with peers. For this rapid learning and sharing to take place, we need
what we currently do not have: a robust learning system through which to learn, collect, and
share data, identify effective interventions using safety science, and spread best practices
about safety in the home setting. This learning system must embrace safety science and
educate individuals and teams on its core elements, including systems thinking, teamwork,
balancing “no blame” with accountability, the human factors involved, improvement science,
high reliability, and safety culture. In contrast to an improvement collaborative, which has a
specified end date, this learning system would be an ongoing project to exchange data on
multiple sources of harm and share best practices related to preventing them.
System for measurement. As previously mentioned, one of the most significant gaps in
research on care in the home is the lack of a common system for measuring safety among all
who provide care in this setting. Identifying and vetting a standard set of metrics is essential
for substantial movement forward. It would be prudent to begin with a simple set of measures
that identify the most prevalent adverse events occurring in the home. From there, the
measure set could evolve as the field matures and more is known about the harms that occur
in the home.
Sharing data. Experience with Solutions for Patient Safety (SPS), a network of more than 130
children’s hospitals that work collaboratively toward the goal of zero harm, has demonstrated
that widely sharing safety data and best practices can significantly improve pediatric patient
safety across multiple health care organizations. SPS shows that it is possible to build a
learning system with data sharing, a social network, and a shared goal. Data collected from
early adopters can be instrumental in turning attention to the scope of the health care harm
occurring in the home and motivating other organizations to improve.
Improvement skills. If safety in the home is to improve, all home care workers must have the
requisite improvement skills, such as the ability to effectively define the problem and test an
intervention. They must “own” safety efforts and understand the importance of their
engagement in safety-related activities. The acquisition of improvement skills has been an
important component of progress in patient safety within the hospital setting and must not be
overlooked as a strategy to improve safety in the home. It is essential to teach improvement
skills, safety science, systems thinking, and awareness of human factors within the context of
a systemic improvement model, such as Lean, Six Sigma, or the Model for Improvement.
Providing access to improvement coaches and collecting and sharing data are also critical
aspects of improving safety in the home.2
A collaborative of organizations. Another important element in advancing improvement in
home safety is the development of a collaborative of organizations. Such a collaborative would
collect and disseminate lessons learned, best practices, and data, paving the way for other
organizations to take on this improvement work. With the support of faculty with expertise in
implementation science, the collaborative would train participants and showcase the
effectiveness of a scientific approach to improvement.
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Because of how frequently safety issues related to medication arise and the wide swath of care
recipients at risk, the expert panel suggested medication safety as an ideal focus for initial
collaboratives. (See Appendix B for suggested tactics for advancing medication safety that
could be used to support early collaboratives.)
4) Effective team-based care and care coordination are critical to safety in
the home setting.
The expert panel identified poor care coordination as the most important clinical problem
affecting care safety in the home setting. The current health care system does not sufficiently
enable teamwork among the many professionals involved in a person’s care, including nurses,
therapists, physicians, social workers, managers, and administrators. Although home care
workers often provide care alone, there must be a coordinated team and infrastructure to
support them, providing supervision, management, and accountability.
By improving care coordination, team-based care with effective communication can reduce
the risk of errors, especially at care transitions, as well as the need for family caregivers to
take on the stressful and exhausting role of care coordinator. In addition, community care
resources need to be integrated into the care plan to ensure that available resources are
utilized and coordinated with other care services. Effective care coordination is especially
important for care recipients with mental, behavioral, or cognitive conditions. Using tools
such as standardized handoff templates and the Teach Back method can be helpful in
optimizing care coordination.
It is not only home care workers whose ability to provide well-coordinated care often
encounters obstacles. Other professionals within the larger health care system also face
challenges, such as those related to staffing, regulations, and policies. Nursing, therapy,
administrative, and management personnel must be considered in any strategy to improve
the safety of care in the home.
5) Policies and funding models must incentivize the provision of high-
quality, coordinated care in the home and avoid perpetuating care
fragmentation related to payment.
Current regulations and payment models often increase care fragmentation. In general,
services paid via fee-for-service models tend to be siloed, leaving important needs unmet. For
example, Medicaid waivers cover only certain services. This payment structure can lead to
narrowly focused care and create perverse incentives to use higher-intensity, more expensive
services. Home- and community-based service organizations must be incentivized to provide
high-quality care that is coordinated and provided in accordance with the values of the care
recipient and family members.
The administrative burdens associated with regulations related to payment for care provided
in the home can overwhelm staff and syphon resources away from care provision. CMS has
taken steps to address this overload by reducing the required fields in OASIS, yet much more
needs to be done.
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Recommendations
To achieve the optimal state described by the guiding principles, the expert panel made the
following recommendations, numbered to correspond with the five principles. A wide array of
stakeholders would be responsible for enacting these recommendations:
• Care recipients
• Clinicians
• Family caregivers
• Health care organization leaders
• Home care workers
• Home health agency leaders
• Payers
• Pharmacists
• Policymakers
• Researchers
• Technology vendors
These stakeholders must work collaboratively to ensure that their implementations of these
recommendations effectively support the guiding principles and advance the safety of care in
the home.
Principle 1: Self-determination and person-centered care are fundamental
to all aspects of care in the home setting.
Recommendation 1.1: Improve communication with care recipients and
family caregivers.
Sample Tools, Strategies, Resources, and Tactics
a. Create a Care Recipient Bill of Rights.
See related resource: Patient’s Bill of Rights
b. Include asking care recipients, “What matters to you?” as a routine component of care.
Conduct a “safety consult” with care recipient, family, and others living in the home after the care recipient
has set goals of care.
c. Ensure home care workers query the care recipient early in the treatment course about the role of
family caregivers in treatment and decision making.
• Include the name of the family caregiver(s) in the health record, in accordance with the CARE Act.
• Consider identifying a medication safety manager for each care recipient; if capable, a family
caregiver could fill this role. The medical safety manager could help ensure the accuracy of
medication reconciliation and regularly inquire as to whether all medications are needed.
d. Provide communication tools for staff at hospital discharge to educate the care recipient and
family caregivers and identify available resources during care transitions.
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Sample Tools, Strategies, Resources, and Tactics
e. Communicate clearly with potential family caregivers about how their role would be defined and
determine their availability for providing various levels of care.
Create and distribute instructional videos for family caregivers on complex care tasks.
Recommendation 1.2: Provide meaningful, relevant education for care
recipients and family caregivers.
Sample Tools, Strategies, Resources, and Tactics
a. Create educational tools (e.g., a one-page information sheet) about self-determination of risks
and safety issues in the home.
Provide tools at inpatient discharge and at first visit to the home.
See related resource: CARE Act
b. Raise awareness of local support groups and other resources for family caregivers.
Consider developing a volunteer “time bank” for family caregivers by which community volunteers can offer
blocks of time to allow caregivers short-term respite from caretaking roles.
See related resource: TimeBanks
Best-practice example: Dementia Care Services Program in North Dakota
c. Co-develop meaningful educational tools to assist the care recipient and family caregivers in
identifying potential hazards and knowing what actions to take if the care recipient needs urgent or
additional care.
• Education about action steps for accessing urgent or additional care can help avoid unnecessary
use of higher-intensity services.
• Consider the use of training consultants.
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Sample Tools, Strategies, Resources, and Tactics
d. Ensure that the care recipient and family caregivers receive appropriate tools and education
about care, including medication safety.
Imparting education and tools is especially important if no family caregivers are available for the care
recipient or a family caregiver cannot be present 24/7.
• Use the Teach Back method.
• Encourage the use of the Ask Me 3 questions to improve communication.
• Provide education for family caregivers as well as care recipients.
Best-practice example: The One Care program for dual-eligible individuals ages 21 to 64 living in
Massachusetts includes principles of independent living in its contract, provides person-centered care, and
involves the care recipient in creating the care plan.
Connect with existing efforts that reframe the language used in conversations about care, such as the Age-
Friendly Health Systems initiative, The Conversation Project, and the Solutions for Patient Safety (SPS)
network.
See related resources:
• Helping Older Adults Improve Their Medication Experience (HOME) by Addressing Medication
Regimen Complexity in Home Healthcare
• HomeMeds Program in Los Angeles
Ensure access to certified shared decision-making tools.
Best-practice examples:
• Operation Family Caregiver, managed by the Department of Veterans Affairs, provides coaching
for family caregivers. (See Appendix A for more information on this exemplar program.)
• North Dakota Dementia Care Services provides education about dementia, referrals to relevant
agencies, and support to the caregivers of people with dementia. (See Appendix A for more
information on this exemplar program.)
Recommendation 1.3: Develop tools to improve person-centeredness in
systems of care.
Sample Tools and Strategies
a. Create a standardized assessment of the care recipient’s functionality and needs (based on his or
her values) that is accessible and can be used by family caregivers and home care workers.
• Include a comprehensive assessment of the care recipient’s health and functional abilities,
socioeconomic status, and the home environment.
• Ensure that assessment areas align with the care recipient’s goals.
• Use professional teams to conduct assessments (e.g., EMS personnel, nurses, behavioral health
specialists).
• Educate home care workers about home assessments.
b. Address legal liability issues that may be barriers to respect for self-determination.
Create disclosures related to safety and risk mitigation in the home to address the legal concerns of home
care workers.
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Sample Tools and Strategies
c. Include care recipients (when they are able) and family caregivers in the care team.
Collaborating and working with family caregivers is essential to effective, safe care.
d. Engage care recipients — and when appropriate, their family caregivers — in co-creating their
care and safety.
Use motivational interviewing to facilitate engagement and better understand barriers to change.
Best-practice example: Aligning Forces for Quality
See related resource: 5 Questions to Ask about Your Medication
e. Promote agency policies that support the assignment of a consistent home care worker.
f. Ensure that functional status measures include a comprehensive scan of the abilities of the care
recipient.
Create functional status assessments that measure more than mobility (e.g., executive function and other
cognitive metrics).
g. Use focus groups and participatory research to understand the priorities of people receiving
home care and their families.
h. Ensure that a member of the care team is available 24/7 to answer the care recipient/family
caregiver dyad’s questions.
• Ensuring the availability of a care team member to answer questions can help avoid ED visits.
• Seek mechanisms to minimize the cost to the care recipient, recognizing that easy access to a
care team member can prevent more costly care.
Principle 2: Every organization providing care in the home must create and
maintain a safety culture.
Recommendation 2.1: Create a vision for a safety culture in the home
health and personal care fields.
Sample Tools, Strategies, Tactics, and Resources
a. Convene a group of innovator organizations to test strategies for defining and developing a
culture of safety that is effective for the field of home care.
• Provide access to experts in reliability from other industries to guide testing and gaining consensus
on an effective strategy for changing culture.
• Ensure the development of a dissemination plan to enable the replication of successful innovations
by others.
b. Consider and discuss safety issues and harm prevention at every encounter with the care
recipient and family members.
Consider safety in the design of technology, communication tools, training, monitoring, and other aspects of
the home care system.
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Sample Tools, Strategies, Tactics, and Resources
c. Acknowledge and highlight the need for balancing safety and risk in the home setting for care
recipients, family caregivers, and home care workers.
Emphasize that balancing safety and risk is essential to providing person-centered care and enabling self-
determination.
d. Prioritize human and financial resources to improve the safety of care in the home.
Ensure that home care workers have access to electronic health records and any other tools necessary for
providing safe care.
e. Adapt or create and disseminate a home care safety culture survey.
Suggest using the Home Care Safety Culture Survey, adapted from the Agency for Healthcare Research
and Quality (AHRQ) Safety Culture Survey by the Center for Patient Safety.
f. Ask care recipients and family caregivers about potential safety gaps and develop tools to reduce
errors.
g. Provide standardized tools for assessing, developing plans for, and executing a sustainable way
to improve safety culture.
Request that AHRQ support the development of a standardized toolkit for home care safety that would be
used across the country.
h. Ensure the inclusion of the care recipient and the person providing care when developing
interventions to improve safety.
Focusing on the partnership between the family caregiver and the home care worker can help ensure that
comprehensive and effective interventions are developed.
i. Create a readiness assessment for home care–related organizations to identify barriers to
adopting safety culture.
Recommendation 2.2: Ensure the emotional and physical safety of family
caregivers and home care workers.
Sample Tools, Strategies, Tactics, and Resources
a. Develop tools to assess the capacity of the family caregiver(s) to provide care in the home.
b. Ensure the availability and use of personal protective equipment for family caregivers and
home care workers.
c. Provide effective training for home care workers and assess learning.
• Create an inventory of current safety training programs and then, based on consensus, develop
a comprehensive modular training program from existing materials.
• Consider including conflict resolution, infection control, personal safety, the use of personal
protective equipment, and violence.
• Consider accreditation requirements regarding the content of training, not just the completion of
training.
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Sample Tools, Strategies, Tactics, and Resources
d. Ensure the support and supervision of home care workers.
• Identify and spread best practices related to workforce supervision; include regulatory agencies
and private care organizations.
• Foster peer communication (both face-to-face and virtual) to address professional isolation.
• Develop a system for measuring performance to ensure accountability.
e. Reduce the risk of injury to home care workers due to crime when working or traveling to and
from the home setting.
Offer de-escalation and self-defense training and consider security personnel for high-risk areas.
Principle 3: A robust learning and improvement system is necessary to
achieve and sustain gains in safety.
Recommendation 3.1: Build a measurement and reporting infrastructure.
Sample Tools, Strategies, Tactics, and Resources
a. Develop a taxonomy of home care as the foundation for a robust reporting system.
b. Support a population-based study to determine the prevalence and types of harm.
• Ensure the adoption of a standard taxonomy related to care in the home.
• Involve AHRQ for funding research.
• Include preliminary work to determine the optimal ways to collect and report data regarding all
care in the home, including identification of the care team members responsible for these tasks.
c. Develop an initial measurement set that is relatively simple to adopt and captures the majority
of harm that occurs in the home setting, based on population-based studies of harm prevalence.
Anticipate that the metrics may evolve over time as understanding of the problem becomes more
nuanced.
• Leverage OASIS as a starting point for measures related to home health; add measures relating
to other components of care in the home.
• Ensure inclusion of the spectrum of harm, including emotional harm, and include events that do
not result in harm (i.e., near misses).
• Align with existing or emerging work on measures — for example, the IHI Skilled Nursing Facility
Trigger Tool for Measuring Adverse Events.
• Consider unintended consequences, such as the cost and administrative burden of data
collection, which could ultimately increase the cost of home health care and render it
unaffordable to care recipients.
See related resource: National Home-Based Primary and Palliative Care Network, which includes home-
based medical practices, professional societies, and patient advocacy groups74
d. Ensure that quality of life is measured, to balance other quality metrics.
Create new Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures to include
metrics of autonomy and expand metrics of quality of life.
See related resource: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Home and
Community-Based Services Survey
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Sample Tools, Strategies, Tactics, and Resources
e. Create robust reporting systems for capturing adverse events in the home, building on OASIS
as an existing resource.
• Enable reporting by care recipients and family caregivers, as well as by home care workers.
• Include the capability for real-time measurement.
• Improve the processes used to detect safety hazards in the home.
f. Develop a process for evaluating the effectiveness of interventions to improve safety in the
home.
Recommendation 3.2: Share data on safety in the home.
Sample Tools, Strategies, Tactics, and Resources
a. Create a culture and expectation of transparency.
See related resource: IHI/NPSF Lucian Leape Institute report, Shining a Light: Safer Health Care
Through Transparency
b. Create a communications strategy to share data widely using standard measurement sets and
any related research studies as close to real time and as frequently as possible.
For example, share analyses of relevant OASIS data.
c. Create materials in a variety of media that explain the need for improvement, making a case for
individuals to adopt the actions and attitudes necessary to improve safety.
d. Based on consensus, develop a comprehensive modular training program from existing
materials.
e. Encourage voluntary reporting of errors in the home to patient safety organizations.
Recommendation 3.3: Teach safety and improvement skills across
the home health and personal care fields and evaluate competency in
these skills.
Sample Tools and Strategies
a. Teach improvement skills and safety science (e.g., human factors, high reliability) to all who
provide care and ensure access to improvement coaches.
Teach improvement skills within the context of a systemic improvement model, such as Lean, Six Sigma,
or the Model for Improvement.2
See related resources:
• The IHI Open School offers education through online courses, connection with local chapters,
and guided improvement projects to build skills in improvement, safety, system design, and
leadership.
• The IHI/NPSF Patient Safety Curriculum, an online course, provides the context, key principles,
and competencies associated with the discipline of patient safety.
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Sample Tools and Strategies
b. Provide action-based and simulation courses to develop leaders with intermediate and
advanced skills.
Include both in-person and distance learning (online) options.
c. Assess competency with improvement skills on a regular basis.
Recommendation 3.4: Create an intensive improvement collaborative for
early adopter organizations.
Sample Tools, Strategies, Tactics, and Resources
a. Identify organizations to participate in an improvement collaborative targeting harm reduction
in the home.
b. Ensure that collaborative members use improvement science and carefully document results.
Focus the initial collaborative on reducing a particular type of risk.
c. Widely share data and lessons learned in the collaborative to encourage other organizations to
adopt best practices.
d. Consider focusing an initial collaborative on improving medication safety.
See Appendix B for more information on advancing medication safety.
Recommendation 3.5: Create a learning system for identifying and sharing
best practices related to care in the home.
Sample Tools, Strategies, Tactics, and Resources
a. Develop a system for identifying models that are successful in improving safety.
b. Create a mechanism for disseminating successful models.
c. Engage researchers to identify pockets of excellence and create aims based on high-
performing groups.
d. Foster the creation of learning networks.
• Willing organizations can share a common goal of eliminating harm across home care, share all
data transparently with each other, and use an “all teach, all learn” approach to identify practices
associated with lower rates of harm and adopt these as standards until better practices are
identified. Lessons learned should be shared widely within and outside the learning network.
• Build on the experience of existing networks in other environments, such as the SPS Network
and the Hospital Engagement Network.
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Principle 4: Effective team-based care and care coordination are critical to
safety in the home setting.
Recommendation 4.1: Create a common, longitudinal care plan based on
the goals of the care recipient or a care recipient/family caregiver dyad.
Sample Tools, Strategies, Tactics, and Resources
a. Consider the care recipient and the family caregiver as a dyad when designing care plans,
policies, and workforce training.
b. Use the hospice and palliative care structure as a model, especially focusing on the
interdisciplinary collaboration, the shared approach to goal-setting, and the communication
methods used.
c. Develop a process for creating and sharing a common, longitudinal care plan.
• Enlist family caregivers to shape the care plan of care recipients who cannot verbalize their
goals owing to mental, behavioral, or cognitive conditions.
• Schedule regular reviews to ensure that the plan remains relevant and supportive of the care
recipient’s needs and preferences.
• Consider the hospice model as a best practice in care plan development and communication.
Review the existing model of Medicaring.org.
Best-practice example: Mobile integrated health care uses physician-led interprofessional teams to
manage care transitions and chronic care services on-site in patients’ homes or workplaces.75
See related resource: Care Plan 2.0
d. Develop processes to communicate elements of the care plan to the care recipient/family
caregiver dyad and the home care workforce.
Adapt and use standardized templates for handoffs between care team members, for example, such
as I-PASS.
e. Develop and regularly share standardized safety messages at every visit.
Use repetition and the Teach-Back method to reinforce and confirm that messages have been
understood.
Recommendation 4.2: Develop and test new models of team-based care.
Sample Tools, Strategies, Tactics, and Resources
a. Support a strong relationship between the care recipient and the home care worker by striving
for the consistent assignment of a worker to a particular care recipient.
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Sample Tools, Strategies, Tactics, and Resources
b. Build new models of service coordination, making sure to include personal care aides and
other home care workers, as well as clinicians ordering home care, on the care team.
• Pilot and test new models, test with other populations, and spread best practices.
• Include interdisciplinary team house calls (e.g., from physicians, nurses, or social workers) and
ensure that behavioral health professionals are included for care recipients with mental,
behavioral, and cognitive conditions.
• Consider primary medical care in the home and alternatives to hospitalization.
• Consider using a tool to track family caregiver and home care workforce hours (existing model:
Medicaring.org).
• Ensure that in the tested model, all members of the workforce are practicing at the top of their
licenses.
• Use common metrics to assess effectiveness.
Best-practice examples:
• Hospital at Home, which provides care for frail older people at home, decreased costs by 30
percent.76 (See the case study in Appendix A.)
• Research is available from an INTERACT (Interventions to Reduce Acute Care Transfers)
intervention to strengthen the relationship between RNs in skilled nursing facilities (SNFs)
and emergency departments (EDs) to work together to reduce the 30-day readmission rate.
The strengthened relationships had a positive impact beyond the immediate problem.77
• The Paraprofessional Healthcare Institute created an advanced aide position to provide
home care aides with coaching and support; the result was an 8 percent drop in ED visits
and improved job satisfaction.
• In the CAPABLE program for aging in place, an occupational therapist, a nurse, and a
handyman work together to understand the care recipient’s goals and make alterations
in the home to support them. A video case study is available online. (See the case study
in Appendix A.)
See related resource: For an evidence-based list of questions helpful at care transitions, see Figure 8.1 in
McLaughlin-Davis’s paper “Case Management Guide to Population Health Management Across the
Continuum of Care.”79
c. Develop systems to help care recipients receive coordinated care services (e.g., with care
managers).
• Designate a “leader” on the care team who communicates with all people providing care in the
home to ensure a coordinated “package” that reflects the care recipient’s values. In addition,
offer a peer navigator (a volunteer with lived experience) to assist the care recipient.
• Ensure that the longitudinal care plan identifies a specific family caregiver, if available, with
whom to communicate.
• Build collaborations to improve medication management, similar to the Pharm2Pharm care
transition program and the Community Care of North Carolina project. (For more information on
these exemplar programs, see Appendix A.)
Best-practice example: The existing model in primary care of using care managers has been shown to
reduce caregiver burden and increase the care recipient’s functional ability.78
d. Expand medication reconciliation to include reviewing medication containers in the home (and
checking their contents).
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Recommendation 4.3: Ensure the visibility and use of community-based
and underutilized resources.
Sample Tools, Strategies, Tactics, and Resources
a. Create a handbook for clinicians and other health care professionals using relevant
community-based resources.
• Ensure that resources for behavioral health are included.
• Annotate the list to assist users in understanding the circumstances under which each resource
is best utilized and why.
b. Include “social prescribing” — referrals of care recipients to a range of local nonclinical
services — in the care plan.
Best-practice examples:
• A prescription for social services such as Meals on Wheels
• UK Social Prescribing Initiative
c. Engage emergency medical services and firefighters in home safety assessments and other
forms of care in the home.
See related resource: See Appendix A for more information on MedStar, an exemplar EMS program.
Recommendation 4.4: Utilize technology to support team-based,
coordinated care.
Sample Tools, Strategies, Tactics, and Resources
a. Reconsider the use of the medical record for home health care.
Consider block chain technology (a decentralized ledger for transferring data without going through a
central clearing source) to allow for communication among team members, the care recipient, and family
caregivers outside the constraints of the electronic health record.
b. Leverage existing data to signal when a care recipient is at higher risk for harm (e.g.,
polypharmacy).
Best-practice example: Collate pharmacy and other data regarding medications to identify potential
medication risks in real time.
c. Expand telehealth programs.
Solicit input from end users for design and use.
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Principle 5: Policies and funding models must incentivize the provision of
high-quality, coordinated care in the home and avoid perpetuating care
fragmentation related to payment.
Recommendation 5.1: Align payment models with the goals of whole-
person, community-based, coordinated care.
Sample Tools, Strategies, Tactics, and Resources
a. Encourage CMS and commercial payers to test new payment models in demonstration projects
and spread effective models.
• Consider financing through community-based organizations rather than the health care system
and identify ways to increase the care recipient’s input on where funds are spent.
• Consider a payment structure similar to that of Medicare Advantage, which requires coordination
with community-based groups.
• Involve:
o Quality Innovation Network–Quality Improvement Organizations (QIN–QIO)
o Physician-Focused Payment Model Technical Advisory Committee (PTAC)
o Center for Medicare & Medicaid Innovation
o Agency for Healthcare Research and Quality
b. Identify and address payment strategies for aspects of care that are currently not covered by
governmental or commercial payers.
Include care for people with mental, behavioral, or cognitive conditions.
c. Address needs for funding long-term home care for populations in need of these services.
Recommendation 5.2: Reduce the regulatory burden.
Sample Tools, Strategies, Tactics, and Resources
a. Identify the key regulatory burdens and advocate for reducing them.
Continue streamlining OASIS by reducing the number of necessary data fields.
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Conclusion
There is no place like home, and people who need care often prefer the home setting to more
clinical environments. Today more of that care is being provided in the home, including
progressively more complex care. For this reason, safety in the home is becoming an increasingly
important issue to address. Given the nature of the home — an individual’s sanctuary and a setting
not under the control of the health care system — we cannot simply apply in the home the safety
principles and strategies that are effective in health care settings.
Gains made by the home health and hospice and palliative care fields have laid a foundation on
which to build, but if safety in the home is to advance, we must pay greater attention to this issue
and follow up with action. We currently do not have a complete understanding of the nature and
prevalence of the risks in the home or full information about the optimal ways to improve safety in
this setting.
What we do know is that a lack of standard measurement across all services, a lack of standard
training and supervision of all members of the home care workforce, and a lack of consistently
effective communication and care coordination represent some of the most pressing safety
problems in this environment. In addition, where best practices are known, they have not been
widely spread and adopted. These are deficits we must address.
As detailed in this report, five key principles shaped the expert panel’s recommendations for
advancing safety in the home:
1) Self-determination and person-centered care are fundamental to all aspects of care in the
home setting.
2) Every organization providing care in the home must create and maintain a safety culture.
3) A robust learning and improvement system is necessary to achieve and sustain gains in safety.
4) Effective team-based care and care coordination are critical to safety in the home setting.
5) Policies and funding models must incentivize the provision of high-quality, coordinated care in
the home and avoid perpetuating care fragmentation related to payment.
Safety in the home is an aspirational goal — one that needs to be established as a core value by
organizational leaders and prioritized as well worth the time, effort, and resources. Safe care in the
home is the care that each of us wants for the people we care about and for ourselves. Now is the
time to begin.
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Appendix A: Case Studies
Community Aging in Place: Advancing Better Living for
Elders (CAPABLE)
I. Background of the Problem
For disabled older adults, in particular, caring for themselves (dressing, bathing, toileting, cooking,
and moving about safely) is critical to their ability to remain independent and safe in their home
setting. Insurance and publicly funded programs, however, typically do not cover support services
to help people with such activities. Moreover, medical care delivery in the home often does not
include a comprehensive assessment of a client’s functional abilities in the home environment and
the implications for their safety, nor does it develop an implementation plan that focuses on the
values and priorities that matter most to clients.
II. Description of the Program
Community Aging in Place: Advancing Better Living for Elders (CAPABLE) is a program developed
at the Johns Hopkins School of Nursing under the direction of Sarah L. Szanton, PhD, and adapted
from the Advancing Better Living for Elders (ABLE) program
1
developed by Laura N. Gitlin, PhD.
Designed to help low-income older adults to safely age in place, the program aims to maintain the
client’s independence and safety by modifying the home to promote mobility, managing
medications and health conditions, developing physical strength and balance, and decreasing
isolation and depression. The goal of these strategies is to maximize the client’s health and
function, and ultimately to save money by preventing hospital admissions, reducing injuries from
falls, and avoiding expensive care such as skilled nursing home care. CAPABLE has received
funding from the National Institutes of Health, the Center for Medicare & Medicaid Innovation,
the Robert Wood Johnson Foundation, the AARP Foundation, the John A. Hartford Foundation,
and the Rita & Alex Hillman Foundation.
The program includes these components:
• A focus on the individual’s goals and strengths in self-care, including activities of daily
living (ADLs) such as eating, bathing, dressing, toileting, walking; and instrumental activities
of daily living (IADLs) such as cooking, shopping, doing housework, and laundry
• A comprehensive assessment of the client’s goals and the client’s medical, functional, and
environmental needs
• A philosophy of providing client-directed interventions, based on what is most
important to the client
• An interdisciplinary, collaborative team — including a handyman, nurse, and
occupational therapist — who make regularly scheduled visits over a four-month window to
address the client’s needs, work with the client to solve problems, and assess progress
How the Program Works
CAPABLE targets clients who are age 65 or older, are low-income, have challenges with at least one
ADL, and are cognitively able to follow the plan to achieve their functional goals. The team initiates
the CAPABLE service model by asking clients what is most important to them. For example, their
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responses might include getting out of bed without assistance, taking a bath on their own, cooking
dinner, or safely walking up and down stairs.
Each team member has a specific role:
• The occupational therapist assesses the client’s functional abilities and goals to
educate the client on strategies to enhance mobility, including the proper use of
assistive devices. The therapist also conducts a home safety assessment to identify
opportunities for home improvements.
• The nurse assesses the client’s priorities and goals and determines how the
client’s health conditions, medications, pain, depression, strength, balance, and
nutrition affect daily activities. In coordination with the client, the nurse develops
an action plan that includes medication reconciliation, health education and
coaching, and motivational interviewing. The nurse also communicates with the
client’s health care provider or a pharmacist as indicated.
• The handyman, in collaboration with the occupational therapist and based on
the client’s concerns, performs home modifications (such as repairing flooring and
installing better lighting, stair handrails, bathtub grab bars, and raised toilet seats)
to help the client navigate the home environment more easily and safely.
During four consecutive months, the program allocates 10 one-hour visits by team members (four
nurse visits and six occupational therapist visits) and up to $1,300 for handyman services to
implement the home improvements, based on the occupational therapist’s recommendations and
the client’s priorities (see Figure 1). The program costs approximately $3,000 per client.
Figure 1. Timeline of CAPABLE Program Visits During Four Consecutive Months
III. Program Results
The CAPABLE program has achieved improvements in the quality of care for clients, as well as cost
savings through reductions in hospitalizations and Medicare expenditures. Twenty sites in nine
states have implemented the program.
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Demonstrated results include the following:
After 281 adults (age 65 and older) who were dually eligible for Medicare and Medicaid
completed the 2012–2015 pilot program, 75 percent achieved improved performance of
ADLs. At baseline, participants had difficulty with an average of 3.9 out of eight ADLs,
compared to difficulty with two ADLs after the program, representing a 49 percent
improvement in physical functioning. Participants also experienced reduced difficulty
with IADLs.
2
Depressive symptoms improved in 53 percent of pilot participants.2
Home hazards in the pilot decreased from an average of 3.3 hazards to 1.4 hazards.2
The average cost of the program was $2,825 per participant.2
In an independent program evaluation involving 171 participants, the CAPABLE program
decreased their total Medicare expenditures by reducing inpatient and outpatient expenses,
including reduced readmissions and observational stays.
3
Client confidence in self-care management and behaviors increased.3
IV. Additional Resources
• Johns Hopkins University School of Nursing website. Community Aging in Place: Advancing
Better Living for Elders (CAPABLE) [Web page].
https://nursing.jhu.edu/faculty_research/research/projects/capable/index.html
• Johns Hopkins Medicine: HealthCare Solutions website. CAPABLE: Aging in Place [Web
page]. https://www.johnshopkinssolutions.com/solution/capable
• Institute for Healthcare Improvement website. WIHI: Aging in Place with a Disability and
Dignity [podcast]. February 22, 2018.
http://www.ihi.org/resources/Pages/AudioandVideo/WIHI-Aging-in-place-with-disability-
and-dignity.aspx
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Community Care of North Carolina: CPESN® Network
I. Background of the Problem
Medication safety issues represent a significant patient safety concern in the home setting,
especially among patients with complex medication regimens for chronic illness. Community
pharmacists, who interact frequently with these patients when they pick up their prescriptions,
have the expertise to detect and address drug therapy problems and potential adverse drug events
and therefore can be an important safeguard against medication safety events in the home.
Historically, however, community pharmacists have generally had a limited role in coordinating
care and ensuring patient safety.
II. Description of the Program
Community Care of North Carolina (CCNC), a patient-centered medical home partnership that
serves the entire state of North Carolina, launched a Community Pharmacy Enhanced Services
Network (CPESN® Network) in 2015 through a Health Care Innovation Award Round Two from
the Center for Medicare & Medicaid Innovation. CCNC care management patients visit a
community pharmacy an average of 35 times each year (compared with only three visits to a
primary care provider). The CPESN approach brings together an extensive network of community
pharmacies that provide enhanced medication management services to patients with complex
medical and behavioral health needs. The services go beyond the traditional community pharmacy
model of dispensing medications. The goal of CPESN is to increase care coordination with CCNC
health care providers and thereby improve medication safety and patient outcomes.
The program includes these components:
• Close collaboration of community pharmacists with CCNC care managers and
other health care staff, who refer patients to CPESN pharmacies and collaborate
with CPESN pharmacists to address patients’ medical, social, behavioral, and
medication safety–related needs.
• In-depth patient assessments are conducted by specially trained CPESN
pharmacists in the community pharmacy or home setting to identify medication
safety issues and barriers to care or medication adherence.
• Enhanced medication management services, such as home delivery or
programs to support medication synchronization (filling all prescriptions at the
same time each month), are designed to promote medication adherence and
safety. An electronic pharmacist care plan that uses Health Level-7 (HL7)
standards has a uniform framework for communicating electronic health
information, and contains information about a patient’s medication regimen and
the pharmacist’s recommendations in a form that can be shared with other health
care team members.
• There is a per member per month (PMPM) value-based payment model to
CPESN-participating pharmacists based on patient adherence and risk-adjusted
cost and utilization outcomes.
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How the Program Works
• CPESN pharmacies serve Medicaid and Medicare beneficiaries who have at least one chronic
health condition. CPESN pharmacies identify eligible patients through referrals from CCNC
health care providers or care coordinators, as well as through analysis of Medicaid and
Children’s Health Insurance Program (CHIP) claims data.
• After a patient is deemed eligible for CPESN support, a specially trained CPESN pharmacist
conducts an initial in-depth, 60- to 90-minute assessment with the patient. The pharmacist
may use laboratory, medical, and pharmacy claims data to review the patient’s health
conditions and medications. The assessment focuses on identifying drug therapy problems,
medication side effects, adverse events, and barriers to medication adherence. Assessments
occur in person at the CPESN pharmacy, by telephone, or in the patient’s home.
• Based on the assessment, the pharmacist works with the patient and, as relevant, CCNC staff
to address any medical, social, behavioral, and medication safety–related needs. Possible
steps may include enhanced medication management services, such as home delivery of
medications or support for medication synchronization. Pharmacists may also work with
CCNC staff to adjust medication regimens, develop strategies to support patient self-
management, or refer the patient for behavioral health services or other home- or
community-based services.
• After the initial assessment, the CPESN pharmacist follows up with the patient at regular
intervals (typically ranging from monthly to quarterly) on an ongoing basis, based on patient
need. These follow-up assessments provide an opportunity to evaluate new medication safety
problems and check on the status of previously addressed issues.
• CPESN pharmacists document all findings from their initial and follow-up assessments in an
electronic pharmacist care plan. The care plan is either made available via the CCNC
electronic community health record or embedded in the workflow of the eight vendor systems
commonly used by CPESN pharmacies. The care plan uses existing HL7 standards, thus
facilitating integration with the electronic medical records used by other health care
providers. The care plan details the patient’s medication regimen, the patient’s health
concerns (including drug therapy problems and medication support needs), and the
pharmacist’s recommendations and interventions.
• Pharmacists receive a PMPM payment for their services under a value-based payment model
developed specifically for CPESN pharmacies. The payment model adjusts PMPM payments
based on performance on three Medicare Star adherence measures (antihypertensive,
diabetes, and statin medications), as well as three risk-adjusted outcomes: total cost of care,
inpatient hospitalizations, and emergency department visits. PMPM payments are contingent
on pharmacists completing the electronic care plan.
III. Program Results
Nationwide, 38 other networks representing 35 states have replicated the CCNC CPESN
Network model.
CCNC has successfully scaled the CPESN model across North Carolina, a geographically and
demographically diverse state. As of August 2017, the CCNC CPESN Network consisted of 227
pharmacies, which had collectively provided enhanced medication services to roughly 15,000
individuals. The program has served patients with a wide range of complex health conditions,
demonstrated the feasibility of electronically exchanging information between pharmacists and
other providers, and shown preliminary evidence of improved patient medication adherence.
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Evidence includes the following:
According to an independent analysis of CPESN participants at baseline,
4
more than 70
percent were Medicare-Medicaid dual-eligible, signifying a high level of social need.
Moreover, CPESN participants had poorer health status and greater need for care than the
general Medicare fee-for-service population. Finally, CPESN participants had higher
expenditures, rates of acute care hospitalizations, and rates of outpatient emergency
department visits relative to national and North Carolina averages for Medicare fee-for-
service beneficiaries.
According to unpublished data from CCNC, CPESN pharmacists had exchanged more than
20,000 care plans with health care providers and payers as of June 2017.
5
According to unpublished data from CCNC, baseline results showed 4 to 5 percent higher
medication adherence rates (based on proportion of days covered greater than 80 percent)
among patients served by CPESN pharmacies, compared with patients served by non-CPESN
pharmacies.5
IV. Additional Resources
• Community Care of North Carolina website. Community Pharmacy Enhanced Services
Network [Web page]. https://www.communitycarenc.org/what-we-do/pharmacy/cpesn
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Hospital at Home®
I. Background of the Problem
Hospitalization, especially for older adults, can present significant patient safety risks related to
patients’ immobility and susceptibility to iatrogenic disease and injury. Falls, pressure ulcers,
functional decline, nutritional deficit, loss of muscle mass, health care–associated infections,
confusion, and delirium are all risks associated with the hospital environment. In contrast, the
home environment provides a familiar and lower-risk setting that enables the older adult to
maintain personal comfort, routines, and function.
II. Description of the Program
The Hospital at Home® program, developed in the mid-1990s and launched in the mid-2000s, is
championed by Bruce Leff, MD, at the Johns Hopkins School of Medicine. This program is
designed to provide hospital-level acute care in their homes for older adults with specific
conditions who are at high risk for infection or other potential safety-related adverse events or who
refuse hospitalization.
The program includes these components:
• Assessments are conducted of a patient who requires hospitalization to
determine if the patient’s clinical condition, functional ability, and home
environment are appropriate for in-home care.
• Transportation is provided from an acute or ambulatory care setting to the
home, assisted by medical personnel and with medical equipment as needed.
• Medical care is delivered in the home by physicians, nurses, and other health
care professionals.
• Medical technology is brought to the home, such as intravenous fluids and
medications, oxygen therapy and other respiratory treatments, blood testing
devices, and equipment for x-ray or ultrasound imaging.
• A comprehensive discharge and follow-up plan is developed by the care
team, patient, and caregiver.
How the Program Works
• Hospital at Home targets older adults who present to an emergency department or
ambulatory care site with a clinical condition that requires hospitalization.
• Physicians determine if the patient’s condition could be treated in a home setting by applying
validated eligibility criteria (e.g., community-acquired pneumonia, or exacerbation of a
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chronic condition such as heart failure or chronic obstructive pulmonary disease) and
exclusionary criteria (e.g., suspected heart attack).
• In addition to considering the patient’s clinical condition, staff assess whether the patient’s
home is suitable for care (e.g., sufficient utilities), the patient’s functional ability, and the
patient’s interest in the program.
• After the patient provides consent, the staff develops a care plan, and the patient is safely
transported home, usually by ambulance, and provided with needed medical equipment,
medications, and devices for vital sign monitoring and communication.
• The treatment care plan is implemented by:
o Physicians — who initially evaluate the patient in the home, provide daily or more
frequent visits, and are available 24/7 for urgent or emergent care needs
o Nurses — who visit daily or more frequently based on the care plan
o Home health care staff — who provide medical equipment, oxygen support, skilled
therapies (e.g., physical therapy), and pharmacy support
• Emergency access via an emergency call button is provided to patients who lack support from
family or caregivers.
• After the patient is stable and no longer requires Hospital at Home care, the care team
develops a comprehensive discharge and follow-up plan with the patient and shares it with
the patient’s primary care physician.
III. Program Results
The Hospital at Home program has been adapted by other health systems and in many Veterans
Affairs (VA) medical facilities. The Center for Medicare & Medicaid Innovation funded a grant to
the Icahn School of Medicine at Mount Sinai to test an adaptation of the Hospital at Home model,
called Hospital at Home Plus.
6
In addition, the program sponsors of the adaptation seek to inform
possible Medicare bundled-payment options.
7
The program has demonstrated improvements in the quality of care for patients and cost savings
through reductions in hospitalizations and Medicare expenditures. Evidence includes the
following:
In a study performed in three Medicare-managed care health systems and a US Department
of Veterans Affairs medical center involving patients who were age 65 and older:
8
o Patients treated in the Hospital at Home model had a shorter length of stay than those in
acute care (3.2 versus 4.9 days), based on an intention-to-treat analysis.
o In three sites studied, 69 percent of eligible patients in two sites chose Hospital at Home
care over hospitalization; 29 percent of those in the third site chose it.
o The mean cost of Hospital at Home care was lower than acute hospital care ($5,081
versus $7,480).
o The rate of complications was lower in the Hospital at Home patients (e.g., delirium
occurring in 9 versus 24 percent of patients, as well as reductions in falls, nosocomial
infections, and urinary complications).
o At eight weeks after admission, there were no differences between hospitalized patients
and Hospital at Home patients in their use of health care services, (e.g., emergency
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department visits), inpatient readmissions, skilled nursing home admissions, or home
health care services.
In New Mexico’s Presbyterian Healthcare Services system, a study involving 582 Medicare
Advantage and Medicaid patients with a comparison group of similar patients showed that:
9
o Mean costs for Hospital at Home patients were 19 percent lower than for the comparison
group.
o The mean length of stay was 3.3 days for Hospital at Home patients versus 4.5 days for
the comparison group.
o The program’s patient satisfaction mean score was higher than for comparable
hospitalized patients (90.7 versus 83.9).
o Hospital at Home patients had no falls, while falls occurred in 0.8 percent of the
comparison group.
In a small randomized controlled trial at two Brigham and Women’s Hospital locations:
10
o Median direct costs for Hospital at Home patients were 52 percent lower than for the
control group.
o Hospital at Home patients engaged in more physical activity per day (median 209 versus
78 minutes).
o Hospital at Home care patients had fewer readmissions within 30 days (11 percent versus
36 percent).
IV. Additional Resources
• Hospital at Home website. http://www.hospitalathome.org
• Johns Hopkins Medicine: HealthCare Solutions website. Hospital at Home [Web page].
https://www.johnshopkinssolutions.com/solution/hospital-at-home
• Presbyterian Services and Centers website. Healthcare at Home [Web page].
https://www.phs.org/doctors-services/services-centers/Pages/home-healthcare.aspx
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MedStar Mobile Healthcare: Mobile Integrated
Healthcare
I. Background of the Problem
Left unidentified and unaddressed, the medical, social, and patient safety concerns that arise in the
home can increase the burden on emergency medical services and emergency departments. In
particular, patients with complex medical conditions and/or challenging socioeconomic situations
may be more reliant on emergency health care resources because they may face multiple barriers to
accessing health care and other services, have unmet medical and social needs, or grapple with
unsafe home conditions. Paramedics are proficient in interacting with patients in home settings
and can respond quickly when patients need help. Paramedics thus represent an important
resource for providing critical support and services to individuals who face safety and health care
challenges at home.
II. Description of the Program
MedStar Mobile Healthcare, an EMS provider in the greater Fort Worth, Texas, area, developed a
suite of programs designed to leverage the skills and expertise of paramedics to intervene with
high-risk, high-need patients in home settings. These Mobile Integrated Healthcare (MIH)
programs aim to ensure that patients receive safe, effective care in the most appropriate setting.
Each of the MIH programs includes these components:
• Processes to identify patients who are eligible for the program.
• In-depth, home-based visits are conducted by specially trained Mobile
Healthcare Paramedics (MHPs) to identify patients’ medical, social, behavioral,
and safety-related needs.
• Bimonthly care coordination meetings are held in which a MedStar
program coordinator confers with hospital caseworkers, community service
agencies, and other care providers to review the needs of enrolled patients.
• Alternative services help patients avoid having to call for EMS, including the
ability to request a home or telephone visit from an MHP instead of calling 911.
• A continuously updated electronic medical record provides mobile access to
information about the patient’s entire course of assessments and treatments
while participating in the program.
• Contractual arrangements exist between MedStar and hospitals,
commercial insurers, and other health care service organizations to receive
payments for the MIH services.
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• MedStar identifies patients who qualify for its MIH programs using a variety of approaches
and data sources:
o MedStar identifies patients for the High Utilizer Program (those who have called 911 at
least 15 times in the past 90 days) by analyzing 911 utilization data and receiving referrals
from emergency departments, frontline MedStar staff, and other first-responder agencies,
as well as agencies and payers partnered with MedStar.
o Participating hospitals and physicians refer patients assessed as being at high risk for
readmission within 30 days of discharge to the Readmission Prevention Program.
o Agencies partnered with MedStar refer patients to the Home Health Partnership
Program, the Hospice Revocation Avoidance Program, and the Observation Admission
Avoidance Program.
• After a patient is deemed eligible for one of MedStar’s MIH programs, a specially trained
MHP or a representative from a partner organization contacts the patient to explain the
benefits of the program. If the patient agrees to participate, the patient signs a consent form
authorizing the appropriate parties to share relevant patient information via the electronic
medical record system.
• The MHP conducts an in-depth, in-home visit with the patient, family members, and
caregivers. During the visit, the MHP performs a full medical assessment, evaluates the
patient’s home environment and safety-related factors, and identifies opportunities to enroll
the patient in other programs to help meet the patient’s clinical, social, or behavioral health
needs (e.g., medication compliance, nutritional support, healthy lifestyle changes).
• Based on the assessment findings, the MHP works with the patient and family to develop or
reinforce an individualized care plan, in coordination with the patient’s primary care network.
This plan outlines the patient’s needs, associated goals, and steps needed to reach the goals.
The patient and family members receive a copy of the plan, which is entered into the
electronic medical record system and thereby is readily accessible to MHPs and other
providers.
• The patient receives a telephone number to use to request an MHP home or telephone visit as
an alternative to calling 911. Because MedStar is the 911 provider in the service area, if the
patient calls 911, the MHP is dispatched to the patient’s location, along with the normal EMS
system response. Once on scene, the MHP may apply established care protocols to address
the patient’s needs, thereby preventing an unnecessary ambulance transport.
• The MHP conducts periodic follow-up visits with patients based on their needs. These visits
provide an opportunity to evaluate any new medical or safety needs, monitor progress in
meeting care plan goals, and provide the patient with additional supports or referrals.
• A MedStar MIH program coordinator meets bimonthly with hospital caseworkers,
community service agencies, and other care providers to review the needs of patients who are
enrolled in the program and to coordinate resources.
• Some of MedStar’s MIH programs have a formal “graduation” process for patients whose
social and safety needs have been addressed and who can manage their own health care
needs.
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III. Program Results
MedStar’s MIH programs have garnered domestic and international interest as a promising
strategy to address the health care and home safety needs of patients with complex medical
conditions. MedStar has hosted site visits by representatives of more than 221 communities from
46 states and seven other countries who are interested in learning how the MIH programs work
and replicating the MIH model.
Across its portfolio of MIH programs, MedStar has “graduated” more than 8,500 patients.
MedStar’s MIH programs have improved the quality of life for enrolled patients and reduced EMS
transports to the hospital, ED visits, and hospital admissions, suggesting that the health of these
patients is better because their health and safety needs were addressed at home.
Evidence includes the following:
A retrospective evaluation assessed pre- and post-intervention data for 64 patients who
completed MedStar’s MIH High Utilizer Program.
11
The evaluation showed that:
o Patients who had reported problems with mobility, pain control, and ability to perform
activities of daily living before participating in the program reported improvements in
these areas (38, 42, and 58 percent, respectively) after participation.
o After participation, 73 percent of patients rated their health as improved.
o Patients had 61 percent fewer EMS transports, 66 percent fewer ED visits, and 56 percent
fewer hospital admissions.
A MedStar report analyzed trends in pre- and post-enrollment utilization data among 581
patients enrolled in the MIH High Utilizer Program between October 2013 and March 2018.
12
The analysis showed that:
o Ambulance transports to the ED were reduced by 5,133 (58 percent), and ED visits and
hospital admissions were reduced by 2,395 and 462, respectively.
o The reductions in utilization decreased health care spending by $9.3 million during the
evaluation period, for a savings of $16,046 per enrolled patient.
MedStar found a total expenditure savings of more than $14 million across all MIH programs
between June 2012 and March 2018.
13
This represents savings of about $3.2 million in
ambulance transport, $4.5 million in ED visits, and $6.4 million in hospital admissions.
Between September 2013 and March 2018, 388 patients identified by a hospice agency as
likely to disenroll from hospice were enrolled in MedStar’s Hospice Revocation Avoidance
Program. Of those, only 18 percent had a disenrollment.
14
The patient experience across MedStar’s MIH programs was favorable, with overall average
ratings ranging from 4.69 to 4.84 on a 5-point Likert scale assessing 12 items related to
patient experience.
15
Between October 2013 and July 2017, 295 patients with a prior 30-day readmission were
identified as being at high risk for another 30-day readmission and enrolled in the
Readmission Prevention Program. Of those, 47.5 percent had a 30-day readmission, which
evaluators considered lower than would have been expected.
16
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IV. Additional Resources
• MedStar Mobile Healthcare website. Mobile Healthcare Programs: Overview [Web page].
http://www.medstar911.org/mobile-healthcare-programs
• MedStar Mobile Healthcare website. MIH-CP (Mobile Integrated Healthcare–Community
Paramedicine) Outcome Measures Project [Web page]. http://www.medstar911.org/mih-cp-
outcome-measures-project
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North Dakota Dementia Care Services Program
I. Background of the Problem
Caregiver safety is essential for patient safety.
17
Approximately 16.1 million Americans provided
unpaid care for people living with Alzheimer’s disease or other dementias in 2017. These caregivers
address a broad range of needs, such as assisting with activities of daily living, care coordination,
and medication management.
18
Collectively, caregivers provided an estimated 18.4 billion hours of
care in 2017, valued at more than $232 billion.
19
The toll of dementia caregiving is well documented. For example, more than 60 percent of
caregivers report facing high or very high stress, and one in four reports clinically significant
anxiety. They are four times more likely to experience depression than noncaregivers and six times
more likely to develop dementia themselves.
20
Such risks, coupled with anticipated new dementia
cases (14 million Americans are expected to have Alzheimer’s disease by 2050, up from 5 million
today),
21
make managing caregiver burden an urgent patient safety and public health issue.
Caregivers for people with Alzheimer’s disease face special challenges in North Dakota, the most
rural state in the nation.
22
Alzheimer’s-related mortality in North Dakota doubled between 1999
and 2014, distinguishing the state as having the nation’s second-highest death rate from the
disease. North Dakota’s 30,000 caregivers for people with Alzheimer’s disease provided 34 million
hours of unpaid care in 2017; they face high levels of stress and depression that impair their own
health and financial security.
23
II. Description of the Program
Established and funded by the North Dakota Legislature in 2009, the Dementia Care Services
Program seeks to help those with dementia and their caregivers understand and safely manage the
disease while reducing caregiver burden. The program does this by assessing needs, identifying
concerns, locating available community services, developing a care plan, providing referrals,
offering support and education about dementia, and following up with families. The program seeks
to help people stay in their homes longer, rely less on emergency and acute care services, delay
premature nursing home placement, decrease rates of caregiver depression symptoms, increase
caregiver empowerment, and increase family support.
The program includes these components:
• Care consultants, social workers or nonclinical staff, receive on-the-job training by serving
as apprentices to program leadership.
• An initial in-depth needs assessment is conducted, with ongoing assessments.
• A tailored care plan describes specific action steps for the caregiver.
• Emotional support and education is provided for patients and caregivers, including (see
Figure 1):
o Access to a consultant via the national Alzheimer’s Association 24/7
Helpline (800-272-3900)
o Consultant follow-up by phone or in person, as needed
o Ongoing consultation sessions, as needed
o Referrals to community services
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Figure 1. North Dakota’s Dementia Care Services Program: Services for Caregivers
How the Program Works
• Recruit caregivers. Trained care consultants with the Alzheimer’s Association Minnesota–
North Dakota Chapter, which administers the program, offer classes at community centers
throughout the state to educate people with dementia and their caregivers about care
planning and program resources. The program is publicized through social services agencies,
health care providers, Veterans Affairs medical centers, senior centers, the media, and word
of mouth.
• Engage caregivers. Alzheimer’s Association care consultants connect with interested
caregivers and schedule a time to meet for a consultation.
• Perform needs assessment and consultation. Care consultants conduct a 60- to 90-
minute initial consultation session, usually in the caregiver’s home. The consultant offers
ways to address safety concerns (such as fall risks or dangers posed by impaired driving). In
addition, the consultant suggests new coping strategies and provides emotional support,
education about dementia, and referrals to support groups and other community-based
services. The consultant also collects information detailing the caregiver’s view of how this
role affects his or her health, family dynamics, and professional life.
• Develop a tailored care plan. At the conclusion of the consultation, the consultant
outlines a care plan and specific steps for the caregiver to take.
• Conduct follow-up consultation. Care consultants conduct one or more follow-up
sessions (either in person or via telephone) — ideally, three times during the first six months.
The consultant assesses caregiver progress with the care plan and helps the caregiver
overcome any barriers to care plan implementation.
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III. Program Results
A formal evaluation by the University of North Dakota School of Medicine20,
24
found:
• Over a three-year period, the Dementia Care Services Program staff provided nearly 3,000
consultations with 1,750 caregivers.
• In survey responses and other self-reported data, the unpaid caregivers credited the
assistance program with helping them feel more empowered. The caregivers had a mean
score of 4.2 (out of a possible 5) when asked to rate the statement: “This program made me
feel better equipped to manage this disease.”
• Program operation cost the state $1.2 million. Estimated savings were $39.2 million from
delayed long-term care placement and $834,000 from reduced use of medical services, such
as hospital stays, emergency department visits, ambulance service, and 911 calls.
• Participation in the Dementia Care Services Program was associated with:
o A 215 percent increase in registration for a commercial location service that offers 24-
hour emergency response for people with dementia
o A 71 percent increase in attendance of dementia education classes
o A 29 percent increase in establishing health care advance directives
o A 24 percent increase in power of attorney designations
Michigan replicated the program as a three-year pilot in three counties starting in December 2014.
The Michigan Dementia Care and Support Program, which targeted individuals with mid- to late-
stage Alzheimer’s disease and their caregivers, was evaluated by the University of Michigan School
of Social Work.
25
Among the program’s 155 caregivers, the evaluators found:
• The percentage of caregivers who said that they received professional support increased from
62 percent in the initial assessment to 92 percent in follow-up assessments.
• The percentage of caregivers who reported feeling confident about dealing with wandering
increased from 22 percent to 46 percent; for helping the care recipient with eating issues, the
percentage increased from 55 percent to 67 percent.
• The program averted an estimated 35 long-term care placements, saving nearly $3 million
and yielding a 434 percent return on investment.
IV. Additional Resources
• Michigan Department of Health and Human Services website. Caring Sheets [Web page for
24 informational “caring sheets” that provide information about dementia and guidance for
caregivers]. http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_29193_85984---
,00.html
• Alzheimer’s Association website. Michigan Dementia Care and Support Program
[informational flyer]. https://www.henryford.com/-/media/files/henry-ford/patients-
visitors/care-and-support-pilot-flyer.pdf
• Klug M. Assessment of the North Dakota Dementia Care Services Program: January 2010
to June 2013. Grand Forks: University of North Dakota School of Medicine and Health
Sciences, Center for Rural Health; July 2013. https://ruralhealth.und.edu/pdf/assessment-
of-the-north-dakota-dementia-care-service-program.pdf
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Operation Family Caregiver
I. Background of the Problem
Families and friends of returning military service members and veterans (numbering an estimated
5.5 million in the United States
26
) often face challenges in providing care, assistance, and support
to service members and veterans who were injured during active duty. In particular, caregivers
may be untrained to deal with the service member’s or veteran’s chronic conditions, such as
traumatic brain injury, post-traumatic stress disorder, or other disability. Caregiver burden and
stress is an important issue for patient safety in the home; caregivers for injured service members
and veterans are at high risk of both emotional and physical harm.
II. Description of the Program
Operation Family Caregiver, developed in 2012 by the Rosalynn Carter Institute for Caregiving,
receives financial support from Johnson & Johnson, the Bristol-Myers Squibb Foundation, and the
Bob Woodruff Foundation. This free program seeks to provide support, counseling, and skills to
the families and friends of newly returning and injured service members and veterans, with a goal
of helping caregivers manage the challenges involved in the transition to the home environment.
The program aims to help caregivers by reducing their perception of burden, decreasing
depression and other health symptoms, improving their life satisfaction, and increasing their
problem-solving skills.
27
The program includes these components:
• Coaches who understand military culture, serve military families, possess excellent
communications skills, and preferably have prior military experience.
• Training for coaches in using Operation Family Caregiver resources, guides, and tools.
• Training for families on effective problem-solving processes, self-care, and safety.
• Broad program access through in-person or virtual communications.
How the Program Works
The program is customized to the individual needs of the caregiver and family but the intervention
generally includes the following activities over a four- to six-month period:
• Following a referral to the program, the coach reviews background information about the
caregiver and family.
• During the first week of the program, the coach meets with and begins to establish rapport
with the caregiver (in the caregiver’s home, at a program service center, or through a virtual
communications platform).
• In weeks 2 to 4, in face-to-face interactions, the coach introduces resources and the problem-
solving process to the caregiver. Based on the caregiver’s assessment and prioritization of
problem areas, the coach works with the caregiver to identify realistic solutions that could
solve the problems identified.
• The coach helps the caregiver assess both the positive and negative effects of the solutions
identified, supports the caregiver using role-play, and aims to instill confidence that the
caregiver has the strengths and experiences needed to carry out the solutions.
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• In weeks 5 to 7, the coach makes follow-up telephone calls to encourage and counsel the
caregiver and receive status updates.
• In weeks 8 to 10, the coach meets face-to-face with the caregiver to discuss how to apply the
problem-solving process to the solutions and to reinforce the importance of the caregiver’s
self-care.
• In weeks 11 to 12, the coach makes follow-up telephone calls to encourage and counsel the
caregiver and receive status updates.
• In weeks 13 to 15, the coach meets face-to-face with the caregiver to review the problem-
solving process, reinforce the caregiver’s self-care strategies, and address safety issues,
including helping the caregiver develop a personal safety plan. As a part of the safety alerts
protocol, caregivers gain knowledge about suicide prevention, including signs of suicidal
ideation in the care recipient and methods for responding effectively.
• In weeks 16 to 18, the coach makes follow-up telephone calls to encourage and counsel the
caregiver and receive status updates.
• In weeks 19 to 24, the coach meets face-to-face with the caregiver to review the program
components and acknowledge the caregiver’s achievements and progress.
III. Program Results
The Operation Family Caregiver Program has nationwide reach through 11 service center locations
and provides caregiver access to program staff from anywhere in the United States via a virtual
communications platform (see Figure 1).
Figure 1. Operation Family Caregiver Program Locations
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A two-year pre-post research design study at nine sites included 128 caregivers for military service
members and veterans in the Operation Family Caregiver Program.27 Results showed the following
changes in instrument scores at follow-up compared with baseline (statistically significant, p <
.0001, except as noted):
• Caregiver burden was reduced (−1.94 change in mean score on the Zarit Burden Scale).
• Depression levels for caregivers were reduced (−7.8 mean score on the Center for
Epidemiologic Studies Depression Scale).
• Caregivers reported fewer physical symptoms (−9.69 mean score on the Pennebaker
Inventory of Limbic Languidness Scale).
• Caregiver negative problem-solving orientation was reduced (−6.47 mean score on the Social
Problem Solving Inventory NPO).
• Caregiver positive problem-solving orientation was increased (+5.29 mean score on the Social
Problem Solving Inventory PPO).
• Caregivers reported greater satisfaction with life (+3.34 mean score on the Satisfaction with
Life Scale).
• Parental reports of child anxiety were not significantly reduced (−1.69 mean score (p = .07)
on the Spence Children’s Anxiety Scale: Parent Version).
IV. Additional Resources
• Operation Family Caregiver website. http://www.operationfamilycaregiver.org
• Rosalynn Carter Institute for Caregiving website. Operation Family Caregiver [Web page].
http://www.rosalynncarter.org/OpFamCaregiver/
• Blue Star Families website. Operation Family Caregiver Coaching Program [Web page].
https://bluestarfam.org/resources/family-life/operation-family-caregiver
• Florida State University: College of Social Work website. Operation Family Caregiver [Web
page]. https://csw.fsu.edu/service/operation-family-caregiver
• Riverside Health System: Center for Excellence in Aging and Lifelong Health website.
Operation Family Caregiver [Web page].
https://www.riversideonline.com/cealh/services/operation-family-caregiver.cfm
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Program of All-Inclusive Care for the Elderly (PACE)
I. Background of the Problem
As a way to optimize the care of nursing home–eligible individuals receiving care at home or in a
community-based setting, in 1990 the federal government began offering states Medicaid waivers
to enable experimentation with value-based service models. The Program of All-Inclusive Care for
the Elderly (PACE), an initiative originally developed by San Francisco’s On Lok Senior Health
Services, was among the first programs. PACE aims to avoid nursing home placement by providing
a broad range of care services to Medicare and Medicaid beneficiaries who clinically require a
nursing home level of care. The program provides flexibility for caregivers; offers tailored services
that manage the complex medical, functional, and social needs of frail elders; and promotes
adherence to home safety standards.
Congress authorized 10 PACE replication sites in 1986 and codified PACE as a permanent
Medicare program in the Balanced Budget Act of 1997. To date, 31 states offer PACE options to
frail elders; 90 percent of PACE enrollees are eligible for both Medicare and Medicaid.
28
II. Description of the Program
For individuals who are deemed eligible for a nursing home level of care by their state’s
administering agency, PACE offers an alternative option: living in their homes and communities
while receiving coordinated, highly tailored health care services spanning the care continuum.
Eligible seniors are assigned to a specific PACE organization that includes an interdisciplinary
team comprising clinicians and support service providers. The interdisciplinary team is responsible
for conducting initial and periodic participant assessments, performing care planning, and
coordinating 24-hour care delivery.
The program includes these components:
• Initial and ongoing assessments by the interdisciplinary team
• PACE center services (such as adult day and social programs, primary and preventive care,
restorative therapy, nutrition services and meals, pharmacy, social services)
• Transportation for participants
• Mental health care services
• Care coordination
• Assistance with activities of daily living
• Prescription medications
• Emergency services
How the Program Works
PACE organizations provide a wide range of services, including adult day programs, primary and
preventive care, nutritional support, pharmacy services, social services, transportation, and other
support services. Members of the interdisciplinary team (see Figure 1) coordinate services, based
on a comprehensive baseline needs assessment. Within 30 days of enrollment, beneficiaries
receive in-person assessments conducted by the interdisciplinary team, including an in-home
assessment by a team member. Additional assessments are conducted at least every six months
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thereafter. Care is provided at PACE centers, at home, or in the community through contracts with
other community-based providers. PACE center safety standards, outlined in federal regulations,
address wheelchair accessibility, handrails, safe water temperatures, housekeeping chemical
storage, cleanliness, and infection control protocols.
Figure 1. Members of the PACE Interdisciplinary Team
At a minimum, the assessments address the following health and safety concerns:
• The home environment, including the ability to safely enter and leave the home
• Physical and cognitive function
• Medication use
• Participant and caregiver preferences for care, including advance care planning and
participant goals of care (person-directed care)
• Socialization and availability of family support
• Current health status and treatment needs
• Nutritional status
• Participant behavior
• Psychosocial status
• Medical and dental status
• Participant language and cultural needs
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Based on the assessment findings, the interdisciplinary team creates a tailored care plan with a
strong prevention component. If the participant is hospitalized or enters a skilled nursing facility,
the interdisciplinary team often participates in clinical rounds that involve the participant.
The program is funded by a combination of sources, including Medicare, Medicaid, and private
payers. Reimbursement is a fixed per member per month fee that covers the entire spectrum of
participant-tailored services that care for the whole person. Because PACE assumes the full risk of
the participant, the organization may find it cost-effective to provide interventions that are not
traditionally covered by Medicare or Medicaid. For example, if the interdisciplinary team
determines that a participant needs to have an air conditioner installed in his or her apartment
perhaps because of a pulmonary condition, the program could cover that expense.
III. Program Results
• A 2014 federally supported evidence review suggested that PACE is cost-neutral relative to
traditional Medicare.
29
It also noted that PACE enrollees experience fewer hospitalizations
than their counterparts in fee-for-service Medicare. Of the studies included in the review, the
one with the strongest evidence rating found that PACE enrollees were nearly 30 percent less
likely to be hospitalized than a matched comparison group.
30
• A 2016 Commonwealth Fund report suggested that the original (On Lok) PACE program’s
30-day readmissions rate was half that of other Medicare beneficiaries.
31
• A 2015 study found that PACE enrollees had a 31 percent lower risk of long-term nursing
home admission than enrollees of Medicaid home- and community-based waiver programs,
suggesting that PACE may help reduce long-term nursing home utilization.
32
• Approximately 93 percent of PACE participants report that they would recommend the
program to a friend or relative. 31
IV. Additional Resources
• National PACE Association website. Helpful Links [Web page].
https://www.npaonline.org/policy-advocacy/state-policy/helpful-links
• National Archives and Records Administration, Office of the Federal Register. Part 460:
Programs of All-Inclusive Care for the Elderly (PACE). Electronic Code of Federal
Regulations (eCFR). https://www.ecfr.gov/cgi-bin/text-
idx?SID=d0ac3a6d03cfe28139f1b3ebc3b6cc7d&mc=true&node=pt42.4.460&rgn=div5
• Centers for Medicare & Medicaid Services. CMS Manual System: Programs of All-Inclusive
Care for the Elderly (PACE) Manual [addresses federal regulations for PACE organizations].
Washington, DC: US Department of Health and Human Services; June 3, 2011. Pub. 100-11.
https://www.cms.gov/Medicare/Health-Plans/pace/downloads/r1so.pdf
• CMS website. Programs of All-Inclusive Care for the Elderly (PACE) [Web page].
https://www.cms.gov/Medicare/Health-Plans/PACE/Overview.html
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Pharm2Pharm: Pharmacist-to-Pharmacist Care
Transitions Program
I. Background of the Problem
Medication errors and adverse drug events represent a significant patient safety concern,
particularly for older adults. Medication-related safety issues arise frequently, especially following
discharge from a hospital when hospital staff adjust medications to address the acute reason(s) for
hospitalization. Without close monitoring and follow-up after an individual is discharged home,
these issues can lead to additional hospitalizations that not only are often preventable, but
routinely result in unnecessary medical spending and heightened risks to safety and health that
would otherwise have been avoidable.
II. Description of the Program
The University of Hawaii developed the Pharmacist-to-Pharmacist (Pharm2Pharm) Care
Transitions Program through a Health Care Innovation Award Round One from the Center for
Medicare & Medicaid Innovation, in collaboration with the Hawaii Community Pharmacist
Association (an organization that is no longer active). In operation from 2012 to 2016, the program
aimed to avoid preventable hospitalizations by addressing medication management issues that can
arise for high-risk older adults (ages 65 and older) during transitions of care from the hospital to
home and during subsequent follow-up care in the home setting.
The program includes these components:
• A formal model of care coordination between hospital and community
pharmacists includes tracking of medication safety issues for up to a year after
hospital discharge.
• Specialized training of hospital and community pharmacists enables them to
play a more proactive and integrated role in medication management during
and after the transition from the hospital to home.
• Communication and collaboration with the patient’s primary care
physician or other health care providers helps identify and resolve drug therapy
problems.
• A health information technology system supports medication
management by allowing pharmacists to access the information needed to
identify and resolve drug therapy problems and communicate electronically.
• A new payment approach for community pharmacists that is based on
minimum performance standards.
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How the Program Works
The Pharm2Pharm program includes these activities (see Figure 1):
• Pharm2Pharm targets older adults who have been hospitalized and discharged to home and
are most at risk for subsequent medication-related hospitalizations and emergency
department visits. Criteria for the target group include taking 15 or more medications, having
a history of medication-related hospitalization, or being newly diagnosed with a condition
such as heart failure or diabetes that requires new medication regimens for disease
management.
• Specially trained hospital consulting pharmacists (HCPs) determine patient eligibility for the
Pharm2Pharm program using standardized eligibility criteria. Eligible patients are identified
by review of hospital admission data, referral by hospital care team members, or outpatient
physician referral.
• The HCP introduces the Pharm2Pharm program to the patient. If the patient agrees to
participate, the HCP conducts an in-depth review and reconciliation of the patient’s
medications, provides education about the medications, and discusses any new medications
that were ordered for the patient during the hospitalization.
• Prior to hospital discharge, the HCP works with the patient to schedule a follow-up
appointment with a community-consulting pharmacist (CCP). After discharge, the HCP
electronically communicates relevant information to the CCP and calls the patient to ensure
that the patient has necessary medications, answer medication-related questions, and remind
the patient of the appointment with the CCP.
• The CCP has follow-up visits with the patient as needed over the course of the subsequent
year, with the goal of ensuring ongoing medication safety in the home setting. The CCP
conducts these visits in person, in the community pharmacy or patient’s home, or by phone
if requested by the patient. During the visits, the CCP reconciles the patient’s medications
and — based on clinical information available through the state health information exchange
and other health information technology systems — systematically identifies and resolves
drug therapy problems.
• The CCP communicates with the patient’s primary care provider at least quarterly to
summarize his or her visits with the patient. This summary includes the advice given to the
patient, recommendations for the patient’s treatment plan, and pharmacist contact
information. As needed, the CCP also contacts the primary provider if the patient has a
significant change in health status or medications, or to resolve any clinically significant
medication safety issues.
• The CCP uses a standard tool to document interventions and bill for services. A CCP receives
four fixed payments per patient over the course of the year based on meeting minimum
performance standards related to the frequency of patient visits, the timeliness of the first
visit and medication reconciliation post-discharge, and contact with primary providers.
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Figure 1. How the Pharm2Pharm Program Works
III. Program Results
The program has reduced preventable medication-related hospitalizations, and the associated cost
savings have well exceeded program costs. Additionally, the program has captured valuable
information about the reasons behind preventable medication-related hospitalizations and shown
that pharmacists can successfully use health information technology to support medication
management.
Evidence includes the following:
In a quasi-experimental study of individuals ages 65 and older (the target population for
Pharm2Pharm) comparing the six hospitals that implemented the Pharm2Pharm program to
five control hospitals:
33
o Medication-related hospitalizations were 36.5 percent lower in hospitals that participated
in Pharm2Pharm than in comparison hospitals (46 per 1,000 versus 72 per 1,000,
respectively).
o Estimated cost savings resulting from hospitalization reductions were $6.6 million per
year, exceeding the $1.8 million annual costs of the HCPs and CCPs in the Pharm2Pharm
program.
In an analysis of hospitalizations that did occur among Pharm2Pharm patients after
enrollment in the program:
34
o Of 401 hospitalizations, 26 percent were determined to be medication-related and
potentially preventable, with the most common reasons being nonadherence due to
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patient choice (23.8 percent), untreated condition for which medication is indicated (13.3
percent), dose too high (10.5 percent), and dose too low (10.5 percent).
o The percentage of hospitalizations that were medication-related and potentially
preventable was significantly higher in more rural areas (30 percent) than in urban areas
(17 percent).
Descriptive statistics demonstrated that the pharmacists adopted and meaningfully used
health information technology to support the medication management processes, including:
35
o A prescription fill history query tool to support medication reconciliation
o The community health record, which includes outpatient lab results and information
from acute care episodes, to support the identification and resolution of drug therapy
problems
IV. Additional Resources
• Pharm2Pharm: Standard Operating Procedures. Hilo: University of Hawai’i at Hilo, Daniel
K. Inouye College of Pharmacy, Center for Rural Health Science; May 6, 2014.
http://qioprogram.org/sites/default/files/editors/141/SOPmanual_140506_SIGNED_Pelleg
rin_20170322_FNL.pdf
• Office of Continuing Education. On-line CPE Module: Identifying and Resolving Drug
Therapy Problems across the Continuum of Care [Web page]. Hilo: University of Hawai’i at
Hilo, Daniel K. Inouye College of Pharmacy; July 1, 2015.
http://pharmacy.uhh.hawaii.edu/ce/irdtp.php
• University of Hawai’i at Hilo. Pharm2Pharm [video].
https://www.youtube.com/watch?v=zIjRkXj_48s
• University of Hawai’i at Hilo. Pharm2Pharm Technology HD [video].
https://www.youtube.com/watch?v=QUAZrPVDvnM
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Appendix B: Suggested Tactics for
Advancing Medication Safety in the Home
As mentioned in the body of the report, medication safety could serve as an ideal focus for initial
collaboratives, whose activities could be informed by the suggested tactics described below.
• Raise awareness about medication-related harm.
o Expand education on medication safety for care recipients and family caregivers.
o Create educational materials on medication safety in the home for family caregivers.
o Develop and launch a national campaign on safe medication use in the home to include
high-risk medications, polypharmacy, and safe medication disposal.
o Consider the Centers for Disease Control and Prevention as a source, using data and
materials from the Institute for Safe Medication Practices (ISMP) and other pharmacy
groups.
o Tie efforts to the work of the World Health Organization on medication safety.
o Roll out the education campaign to the public, home health agencies, and other relevant
groups.
For existing work, see: NHS Scotland Polypharmacy Guidance
• Gather data on medication-related harms and effective safety strategies.
o Gather data on factors that lead to medication-related harm in the home.
o Analyze successful community models and the effectiveness of efforts to scale to larger
groups; spread effective models.
o Encourage home care workers to report medication-related events to the Institute for Safe
Medication Practices (ISMP) and the US Food and Drug Administration (FDA).
For existing work, see: Institute for Safe Medication Practices
• Analyze successful community models and the effectiveness of efforts to scale to larger
groups.
o For example, the Program of All-Inclusive Care for the Elderly (see the case study in
Appendix A).
• Optimize medication treatment.
o Use a co-developed treatment plan.
o Reduce inappropriate polypharmacy.
o Improve adherence to medication treatment plans through improved health literacy.
o Assess ability to access needed medication.
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o Proactively address barriers to optimal treatment, such as inability to reach a pharmacy
with the required medication because of physical limitations, socioeconomic issues, or lack
of transportation.
• Expand the use of currently available resources.
o Expand medication reconciliation to include a review of medication bottles (and a check of
their contents) in the home.
For existing work, see: Visiting Nurses Association of America Blueprint for Excellence
(materials on medication reconciliation)
• Expand and promote safe medication disposal programs.
• Consider linking efforts with water protection groups.
• To avoid the diversion of medications, advocate for policy changes to allow palliative care
personnel to dispose of opioids and other drugs after the death of a care recipient.
For existing work, see: Dispose My Meds program from the National Community Pharmacists
Association Foundation
• Expand the role of community pharmacists and pharmacy students by, for example, involving
them in medication reconciliation, counseling, education, and checking medications at the
bedside.
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