Rol van de verpleegkundige in het ziekenhuis

Rol van de verpleegkundige in het
ziekenhuis
Prof. Walter SERMEUS
Leuvens Instituur voor Gezondheidszorgbeleid
KU Leuven
07.11.2015
Inhoud
•  Organisatie van ziekenhuizen
Vier werelden van Mintzberg
o  Organisatie verpleegkundig departement
o  Divisie-organisatie / Service-line organisatie
•  Het RN4CAST onderzoek - Bevindingen
o  Verpleegkundige bestaffing
o  Impact van kwalificatiegraad
o  Impact van werkomgeving
•  Het RN4CAST onderzoek – Aanbevelingen
o  Safe staffing ratios
o  Full BSN staff
o  Magneetziekenhuizen
o 
Management van ziekenhuizen
•  Ziekenhuizen zijn grote bedrijven:
o 
o 
Niet vaak opgenomen in Trends Top 20000
Maar vaak wel bij de grootste werkgevers in de streek
•  Complexe organisaties - nood aan goed management
•  “Running even the most complicated corporation must
almost be child’s play compared to managing any hospital”
(Mintzberg, 1997)
Definitie van een ziekenhuis
•  Art.2 Wet op de ziekenhuizen (2/8/86)
o 
o 
Ziekenhuis is een opdracht
“ medisch-specialistische zorg in een samenhangend
en multidisciplinair verband met de bedoeling bij de
patiënt op een zo kort mogelijke tijd de ziekte te
bestrijden of te verlichten, de gezondheidstoestand te
herstellen of te verbeteren of de letsels te stabiliseren”
Organigram Belgisch ziekenhuis
(ziekenhuiswetgeving: 2/8/86)
Algemeen directeur
Medische
raad
DIRECTIE
Hoofdgeneesheer
Administratief Directeur
Verpleegkundig Directeur
Medisch diensthoofd
Boekhouding/Administratie
Personeelsdienst
Sociaal werk
...........
Verpleegkundig Middenkader
Hoofdverpleegkundige
Artsen
Verpleegkundige
logistiek medewerker
verzorgende
ZIEKENHUIS
Duale ziekenhuisoranisatie
•  Historisch gescheiden – organisatorisch / financieel
•  Duaal functioneel organisatiemodel:
Artsen: professionele organisatie; bottom-up; op basis
van standardisatie van bekwaamheid; vlakke
organisatie
o  Niet-artsen: machine organisatie: top-down; op basis
van procedures; hierarchisch
•  Van duaal naar 4 werelden: Glouberman & Mintzberg,
Managing the care of health and the cure of disease,
Health care Management Review, (2001)
o 
4 werelden in het ziekenhuis
DISCONNECTIE
Glouberman & Mintzberg, Health care management Review, part I, 2001
4 werelden in de gezondheidszorg
DISCONNECTIE
Glouberman & Mintzberg, Health care management Review, part I, 2001
Coordination (1) & Collaboration (2) Issues
Glouberman & Mintzberg, Health care management Review, part II, 2001
Models of Clinical coordination –
Stacey Diagram
LOW
20%
LEVEL
OF
AGREEMENT
20%
60%
HIGH
HIGH --- PREDICTABILITY --- LOW
Glouberman & Mintzberg, Health care management Review, part II, 2001
Functionele organisatie
cfr. ziekenhuiswet
Algemeen directeur
Medische
raad
DIRECTIE
Hoofdgeneesheer
Administratief Directeur
Verpleegkundig Directeur
Medisch diensthoofd
Boekhouding/Administratie
Personeelsdienst
Sociaal werk
...........
Verpleegkundig Middenkader
Hoofdverpleegkundige
Artsen
Verpleegkundige
logistiek medewerker
verzorgende
ZIEKENHUIS
Organisatie van het verpleegkundig departement
K.B. van 7 augustus 1987 - wet 29 december 1990
Divisie organisatie
directie
Stafdienst
(functioneel)
Balanced scorecards
Boordtabellen
Profitcenter
Primaire Divisie A
Bv. hartziekten
Primaire Divisie B
Bv. geriatrie
costcenter
Secund. Divisie C
Bv. Med.
beeldvorming
Secund. Divisie D
Bv. hoteldienst
Soms meervoudige leiding
- 
- 
- 
- 
Artsen
Verpleegkundigen
Adminstratie
….
SLA: Service Level Agreement
X
medical
department
SERVICE-LINE/PROCES ORGANISATIE
X
hospital wards
hospital
wards
X
Pa1
X
Pa2
X
Pa3
X
X
one day
one day
hospital
hospital
outpatient clinic
outpatient
clinic
operating
operating
theatres
theatres
X
X
ancillary
ancillary
department
department
X-ray LAB ETC
pharmacy
icu
Service-line
PRA
X
X
PRB
X
TENSOR
nursing
department
supporting
departments
paramedical
departments
X
X
X
Evolueren van een functionele naar
een procesorganisaties
Mc Cormack & Johnson , 2001
Clinical Microsystems
•  Definition – A Clinical Microsystem
is:
o 
o 
o 
o 
o 
o 
a small group of people
who work together on a regular
basis
and a shared information
environment.
•  Staff focus
•  Education &
Training
•  Interdependence
of care team
•  Leadership
•  Organizational
support
to provide care to discrete
subpopulations of patients.
It has clinical and business aims,
linked processes,
Staff
Leadership
Information
&
Information
Technology
Performance
•  Performance
results
•  Process
improvement
•  The Microsystem consists of the
people, the patients and the
information system.
Nelson & Batalden, 2007 (www.clinicalmicrosystem.com)
Patients
•  Patient Focus
•  Community &
Market Focus
Relational Coordination
Coordinating
Mechanisms
Clinical Pathways
Case Managers
Interdisciplinary Rounds
Staff Focus
Control Mechanisms
Selection
Performance Measurement
Rewards
Conflict Resolution
Gittell J. et.al., 2000
Relational Coordination
Outcomes
Quality
Communication
Frequent
Timely
Accurate
Problem Solving
Efficiency
Relationships
Shared Goals
Shared Knowledge
Mutual Respect
GRPI-model of team effectiveness
% team conflicten
Rubin, Plovnik & Fry, 1977
Inhoud
•  Organisatie van ziekenhuizen
Vier werelden van Mintzberg
o  Organisatie verpleegkundig departement
o  Divisie-organisatie / Service-line organisatie
•  Het RN4CAST onderzoek - Bevindingen
o  Verpleegkundige bestaffing
o  Impact van kwalificatiegraad
o  Impact van werkomgeving
•  Het RN4CAST onderzoek – Aanbevelingen
o  Safe staffing ratios
o  Full BSN staff
o  Magneetziekenhuizen
o 
RN4CAST STUDY
7th Framework Programme for Research
and Technological Development
§  ‘RN4CAST: nurse forecasting in Europe’: €3 million funding for 2009-2011
q  Health theme 3: Optimising the delivery of health care
q  16 partners: 12 European countries, USA, China, South-Africa,
Botswana
q  Co-ordination: Leuven University (W. Sermeus), U. Pennsylvania (L. Aiken)
Sermeus et al., 2011 BMC Nursing
20
RN4CAST Framework
Framework: A nursing organization model
Dubois et al., 2012, BMC HSR
RN4CAST DESIGN
§  Multicountry, multilevel, cross-sectional design to obtain important
unmeasured factors in forecasting models, collected at the hospital,
nursing unit and individual nurse and patient level:
§ 
Nurse survey: working environment, quality & safety, staffing
Patient survey: patient experiences with nursing staff, hospital,
information
§ 
Hospital survey: type of hospital, inflow & outflow
§ 
Hospital Discharge data: ICD9/10, length-of-stay, adverse events,
mortality
§ 
§  Setting
§ 
At least 30 general acute hospitals in each European country.
§ 
At least 2 general surgical and internal medicine wards in each hospital.
Sermeus et al., 2011 BMC Nursing
22
RN4CASTSTUDYDESIGN&SAMPLE
Europe(12countries)
33,731nursesin486hospitals
11,318paFentsin210hospitals
Portugal
2,235nursesand2,223
paFentsin31hospitals
U.S.(PA,CA,NJ,FL)
27,509nursesin617hospitals
MillionsofpaFentsin430hospitals
Italy,Cyprus,…
>40hospitals,>5000nurses
China(6prov.,2mun.,1aut.reg.)
9,698nursesin181hospitals
6,494paFentsin181hospitals
SouthAfrica(6provinces)
4,657nursesin62hospitals
U.S.2009;2015
RN4CASTEurope2009-2010
RN4CASTICPC2009
RN4CASTExtension2014-15
23
RN4CAST FINDINGS
MORE THAN 50 PEER-REVIEWED PUBLICATIONS (www.rn4cast.eu)
SELECTION OF PUBLICATIONS
§  Aiken et al. 2012 Patient safety, satisfaction, and quality of hospital care: cross
sectional surveys of nurses and patients in 12 countries in Europe and the
United States. BMJ.
§  Aiken et al.. 2014. Nurse staffing and education and hospital mortality in nine
European countries: a retrospective observational study. The Lancet
§  Ausserhofer et al. 2014. Prevalence, patterns and predictors of nursing care left
undone in European hospitals: results from the multicountry cross-sectional
RN4CAST study. BMJ Qual Saf
VARIATIONINNURSESTAFFING(PATIENTSPERNURSE)
Belgium:10.7
6.2-16.2
Finland:8.3
5.3-15.6
Ireland7.0
5.4-8.9
Sweden:7.6
5.4-10.6
Greece:9.8
6.3-15.5
Germany:13.0
7.5-19.2
Portugal:7.7
USA
5.3
Norway:5.4
3.4-8.2
Weightedbyhospitallevel
Spain:12.4
9.4-17.9
England:8.6
5.6-11.5
theNetherlands:7.0
5.1-8.1
China:7.9
Poland:10.4
7.2-14.9
Switzerland:7.9
4.6-12.6
25
South-Africa:
14.3
Percent Bachelor prepared Nurses
100
90
80
70
60
50
40
30
20
10
0
100
51
60
52
59
32
56
22
20
10
0
26
Aiken et al., 2013 IJNS
100
Nursing Education Level in EU/EEA 2015
Requirements for entry into the profession
22
University Training
U/HE Training
HE / Vocational Training
9
(Own compilation of data)
Vocational Training
Nurses’ work environment
Captures 5 dimensions:
q  Staffing adequacy
q  Nursing foundations for
quality
q  Nurse manager ability &
leadership
q  Nurse-physician relations
q  Nurse involvement in
hospital affairs
Hospitals classified into
quartiles by PES scores
Total
England
Sweden
Poland
Norway
Netherlands
Ireland
Greece
Finland
Spain
Germany
Switzerland
Belgium
poor
mixed
better
0% 20% 40% 60% 80%100%
28
Aiken et al., 2013 IJNS
Effect of nurse staffing on patient mortality
29
Aiken et al. 2014 The Lancet
30-day inpatient general surgery mortality per hospital
Nh = 300 Hospitals, Np=422730 patients
(9 European countries: BE, UK, FI, IE, NL, NO, ES, SE, CH)
BE hospitals are marked in red
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
0.00%
1
7
13
19
25
31
37
43
49
55
61
67
73
79
85
91
97
103
109
115
121
127
133
139
145
151
157
163
169
175
181
187
193
199
205
211
217
223
229
235
241
247
253
259
265
271
277
283
289
295
1.00%
MEAN EUROPE: 1.3%, RANGE: 0.0%-7.2%, N=300
MEAN ONE COUNTRY: 1.2%, RANGE: 0.3%-3,0%, N=59
Aiken LH et al…. Sermeus W, Nurse staffing and education and hospital mortality in nine European countries:
a retrospective observational study, The Lancet 26 February 2014
Significant effect
Aiken et al. 2014 The Lancet
Skills perspective: Scope of practice
Care left undone in European hospitals (N=488)
STAFFING LEVELS
Mean percentages (SD)
Ausserhofer et al. 2014 BMJ Q&S
HIGH
MEDIUM
LOW
Scope of practice: Nursing Care Left
Undone because of Lack of Time
33
Ausserhofer et al. 2014 BMJ Q&S
Jobsatisfaction of nurses in Europe
Aiken et al. 2012 BMJ
Intention to leave hospital & profession
35
Heinen et al., IJNS, 2012
Hospitals with Better Work Environments: Lower
Nurse Burnout, in every country
36
Aiken et al. 2012 BMJ
Best
Effect of nurse staffing on nurse outcomes
Aiken et al. 2012 BMJ
Patient satisfaction rates (1-10)
Aiken et al. 2012 BMJ
RN4CAST FINDINGS
PATIENTS’ EXPERIENCES WITH CARE: RELATION TO NURSING
Aiken et al. 2012. BMJ
Relationship of nurse satisfaction and patient
satisfaction
Aiken et al. 2012 BMJ
Likelihood of Poor Patient Outcome
The Effects of Nurse Burnout
on Patient Outcomes
-- 24%
Recommend Hospital
- 27%
Rate Hospital 9 or 10
5
25
45
Percent of Nurses with High Burnout
Inhoud
•  Organisatie van ziekenhuizen
Vier werelden van Mintzberg
o  Organisatie verpleegkundig departement
o  Divisie-organisatie / Service-line organisatie
•  Het RN4CAST onderzoek - Bevindingen
o  Verpleegkundige bestaffing
o  Impact van kwalificatiegraad
o  Impact van werkomgeving
•  Het RN4CAST onderzoek – Aanbevelingen
o  Safe staffing ratios
o  Full BSN staff
o  Magneetziekenhuizen
o 
Safe patient nurse ratios in California
AB 394, 1999 – Required from 2004
•  24/7(per shift, including
• 
• 
• 
• 
http://www.nursingworld.org/
breaks)
Per Nurse
Only RNs (not including
supporting staff)
Not including nurse
managers’ role
Minimal (can be higher
based on PCS systems)
The American Nurses Association’s Nationwide State Legislative
Agenda
NURSE STAFFING
WA
MT
ND
MN
OR
ID
WY
NV
CA
VT
SD
AZ
CO
NM
AK
IL
KS
OK
TX
MO
IN
KY
PA
OH
MS
AL
RI
NJ
MD
wv VA
DE
DC
NC
TN
AR
MA
CT
MI
IA
NE
UT
NY
WI
NH
ME
*
GA
SC
LA
FL
HI
Enacted legislation/adopted regulations to date: (CA, CT, IL, MA, MN, NV, NJ, NY,
OH, OR, RI, TX, VT, and WA) (*DC and ME rescinded AND NC requested study only
2009)
Approaches vary; for specific, refer to report.
http://www.nursingworld.org/
Victoria Nurse-to-Patient ratios
Introduced in 2000, legislated in 2015
Hospital Type
AM shift
PM shift
Night shift
1
1:4 + in charge
1:4 + in charge
1:8
2
1:4 + in charge
1:5 + in charge
1:8
3
1:5 + in charge
1:6 + in charge
1:10
4
1:6 + in charge
1:7 + in charge
1:10
Aged HC Res
Ward
1:7 + in charge
1:8 + in charge
1:15
The Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios)
Bill 2015 was introduced to Parliament on 1 September 2015 and passed
on 8 October 2015.
http://www.health.vic.gov.au/nursing/ratios-legislation
Safe Staffing ratio’s in UK
Directe aanleiding
•  Francis report, The Mid Staffordshire NHS Foundation
Trust Inquiry, 2013
o 
o 
It was the biggest scandal of NHS care in years. Several hundred,
possibly as many as 1,200, patients died at Stafford Hospital
between 2005 and 2009 after suffering neglect, indignity and
shoddy care.
Understaffing meant the hospital's A&E unit often posed a risk to
patients' safety. A shocking catalogue of appalling care included
receptionists assessing emergency cases, patients dying after
falling when they were left unattended and some of the sick being
denied food and drink.
The Guardian, 2011
http://www.midstaffsinquiry.com
NICE guideline for safe nurse staffing
in adult inpatient wards in acute hospitals
•  Determining nursing staff requirements
Procedure
o  Accountability
o  Responsiveness to unplanned care
o  Monitoring adequacy e.g. measuring outcomes
•  Promote staff training and education
•  System of Red Flags
o 
https://www.nice.org.uk/guidance/sg1/chapter/1-Recommendations
https://www.nice.org.uk/guidance/sg1/chapter/1-Recommendations
Safe Nurse Staffing Levels (Wales) Bill
Bill Introduced December 2014
NOW: Stage 2: Committee considerations of Amendments
België: Minimale bestaffingsnormen
Dateren van eind jaren ‘60
Dienst
FTE
Bedden
Bezetting
PatientNurse ratio
C,D
12
30 bedden
80%
10,95
E
13
30 bedden
70%
8,84
M
14
24 bedden
70%
6,57
G
13,3
24 bedden
90%
8,87
ICU
2
Per bed
100%
2,74
= verplicht minimum
+ bijkomende bestaffing via MVG, CAO’s, startbanen, …
Rapport KCE ziekenhuisfinanciering
Roadmap voor een nieuwe ziekenhuisfinanciering in België, KCE rapport 229, 2014
Budget impact
COST EFFECTIVENESS DISCUSSION
•  One RN more will generate 72% of her salary in medical
savings: less deaths, less complications, short length of
stay, less medical costs,…
•  This is only a partial estimate of the economic value of
nursing, omitting the intangible benefits such as:
o 
o 
o 
of reduced pain and suffering by patients and family members;
benefits to the hospital such as improved reputation, reduced
malpractice claims and payouts, and reduced compliance-related
costs;
the benefits of increased staffing related to improved work
environment (e.g. reduced turnover)
Dall et al. 2009 Medical Care
Nurse staffing is a cost-effective
intervention
Rothberg M 2005 Medical Care
Inhoud
•  Organisatie van ziekenhuizen
Vier werelden van Mintzberg
o  Organisatie verpleegkundig departement
o  Divisie-organisatie / Service-line organisatie
•  Het RN4CAST onderzoek - Bevindingen
o  Verpleegkundige bestaffing
o  Impact van kwalificatiegraad
o  Impact van werkomgeving
•  Het RN4CAST onderzoek – Aanbevelingen
o  Safe staffing ratios
o  Full BSN staff
o  Magneetziekenhuizen
o 
IOM report on the Future of Nursing (2010)
RECOMMENDATION
Economic Evaluation of the 80% BSN Nurse –
workforce recommendation
•  Design:
Patient-level analysis of electronic data in 1 hospital
(USA)
o  8526 med-surgical patients, matched with 1477 direct
care nurses
•  Results:
o  Lower mortality (OR=0,89, p<0,01)
o  Lower rate of readmissions (OR=0,81, p=0,04)
o  Shorter length of stay (-2%, p=0,03)
o 
Yakusheva, Lindrooth & Weiss, Medical Care, October 2014
Reaction of a MD on the Aiken et al. Lancet
paper 2014
www.thelancet.com Vol 384 September 6, 2014
What is situation in Europe?
•  DIRECTIVE 2013/55/EU, 20 November 2013, on the
recognition of professional qualifications
•  Art.31, par.4:
o  Theoretical education is that part of nurse training from
which trainee nurses acquire the professional
knowledge, skills and competences required under
paragraphs 6 and 7. The training shall be given by
teachers of nursing care and by other competent
persons, at universities, higher education
institutions of a level recognised as equivalent or at
vocational schools or through vocational training
programmes for nursing.
Nursing Education Level in EU/EEA 2015
Requirements for entry into the profession
22
University Training
U/HE Training
HE / Vocational Training
9
(Own compilation of data)
Vocational Training
Inhoud
•  Organisatie van ziekenhuizen
Vier werelden van Mintzberg
o  Organisatie verpleegkundig departement
o  Divisie-organisatie / Service-line organisatie
•  Het RN4CAST onderzoek - Bevindingen
o  Verpleegkundige bestaffing
o  Impact van kwalificatiegraad
o  Impact van werkomgeving
•  Het RN4CAST onderzoek – Aanbevelingen
o  Safe staffing ratios
o  Full BSN staff
o  Magneetziekenhuizen
o 
Impact van werkomgeving van
verpleegkundigen op kwaliteit van zorg
•  Vijf factoren
o 
o 
o 
o 
o 
Adequaatheid van de verpleegkundige bestaffing
Samenwerking arts – verpleegkundige
Ondersteuning door het management
Betrokkenheid en inspraak in het beleid
Betrokkenheid bij kwaliteit
•  Resultaten van RN4CAST-studie in 12 Europese landen
•  Bevraging van 33000 verpleegkundigen en 11000
patiënten
Nurses Reporting on Hospital Work Environment
Total
England
Sweden
Poland
Norway
Netherlands
Poor
Ireland
Mixed
Greece
Better
Finland
Spain
Germany
Switzerland
Belgium
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Enkele modellen ter verbetering
•  Magneetziekenhuizen
ANCC Magnet Recognition programme (N=395)
www.nursecredentialing.org/
•  Transforming care at the bedside (TCAB)
o  IHI - Reliable Care, Vitality and Teamwork, Patient-Centered Care,
and Value-Added Care Processes www.ihi.org
•  Productive wards (NHS)
o  Lean management & procesoptimalisatie op verpleegafdelingen
o  Meer tijd voor patiënten
o  Institute for Innovation and Improvement - www.institute.nhs.uk
o 
Conclusies
•  Ziekenhuizen zijn complexe organisaties,....
•  .... maar met een organisatiestructuur “from fragmentation
to collaboration”, wordt een ziekenhuis, “more manageable
than anyone thought” (Glouberman&Mintzberg, 2001)
•  Verpleegkundigen vervullen een “onderschatte” sleutelrol
in de gezondheidszorg
BMJ 2015;351:h4652
Dank voor uw aandacht