Having the right data boosts quality, cuts costs

Technology can make you a better manager

Nurses in the neurological ICU managed by Leslie Blatt at Yale New Haven Hospital in New Haven, CT, had a complaint. "The work is harder this year," they told her.

At first blush, Blatt, RN, MSN, MBA, who managed both the neurological and surgical ICUs, was hard pressed to understand why. Perhaps more staffing was needed, she admits thinking at the time.

But before batting heads against the financial powers in hopes of squeezing out some extra funding, Blatt took her nurses' observations to staff at the hospital's Resource Information Management Systems. She consulted Donna Diers, RN, MSN, and Janis Bozzo, RN, MSN, in the hospital's department of operational finance, to see how data could clarify the problem. They decided to look at a number of issues, including lengths of stay, census, age, whether tests were requiring more time from nurses who had to accompany patients, and they also decided to look at the DRG mix.

After the number crunching was finished, the data revealed a different problem than Blatt first considered. The problem wasn't a bigger workload. Instead, the investigation showed that patients in the neurological ICU had been there under 187 different DRG classifications. Blatt says she then realized that the work wasn't harder because of acuity but because nurses were dealing with so many different conditions.

That case study¹ by staff at Yale New Haven Hospital emphasizes how technology has extended nursing duties beyond the patient care realm into the nurse manager role. Having the right data should enable you to better manage resources that are growing scarce.

"Managers need to think about what kind of data they need to manage their units, not just what data the hospital automatically gives them," says Diers. "Most ICU managers really don't have much acquaintance with what is kept in hospital information systems or know what to get out of it."

The Yale New Haven data-producing efforts are beyond those enjoyed by most hospitals. One key difference is that Diers and Buzzo - both registered nurses - provide a bridge between the clinical and financial sides of hospital operations. Nursing managers can talk with them about problems that need to be explored, and they can determine what types of data should be gathered using software from the Transition Systems International company in Boston.

Yale New Haven began using the system about five years ago. It is crucial to the hospital's flexible budgeting system because it can take a retrospective look at volume changes over time and adjust operating budgets accordingly, says Diers. It also has been used for clinical case mix analysis in the following ways:

· to understand difficult-to-manage clinical units;

· to understand why some units are over budget;

· to create an acuity system for the emergency department;

· to anticipate how services will change under disease management for patients with diabetes.

Blatt's exposure to the system made her a believer. Without the ability to capture some hard data, she says she would have agreed with the more popular opinion that more staff were needed. But the analysis showed the impact of a systems change in which the hospital began using the neurological ICU as an overflow area for surgical ICU patients. At times, says Blatt, a third or even half of the NICU beds are devoted to surgical patients.

"When they pulled out that data, what we found was that there were a lot of different types of patients who hadn't been seen before on the neuro side," she adds. "It turned out that the job I thought I had done in educating people hadn't been enough to help them do what they had to do now. Instead of focusing on having more staff members, [the data] told me that what I needed to focus on was to make sure my staff received the education they needed to take care of these types of patients."

Since the study, Blatt has moved to the Hospital of St. Raphael, also in New Haven, where she is a psychiatric nurse specialist. The Transitions Systems International software is being installed there, and Blatt says she's more than pleased.

"For a long time, I had been looking for a way to talk to financial people about the clinical aspects of the situation, and this type of analysis lets you speak their language," she says. "I think it's an excellent way to have people look at what's going on in a unit and make decisions with data, not just on impressions or hunches. Nursing managers are used to saying `Because of my experience and expertise, I believe this and this.' Now they can say `Because of my expertise and my data, I believe this and this.' It basically allows you to show it to the financial people in a language they can understand."

Another advantage is that the information is current, she says. Many data reports that typically come from information systems can be months old, often too old to be useful. The Yale New Haven system produces reports almost immediately. Diers also notes that some of that data is now being made available to nursing managers on their office computers.

The Yale New Haven effort obviously gives the hospital an advantage in the new era of hospital finance, says Diers. "It came to pass long before managed care was on the horizon here, it came from the wish for the hospital to do better, and understand the work better, to be able to manage both cost and quality, which is also the managed care agenda. It comes from the theory that in order to manage your internal processes, which is where you're going to save money, you really have to have the information in both clinical and financial terms."

^Reference

^{1. Diers D, Bozzo J, et al. Understanding nursing resources in intensive care: A case study. Am J Crit Care 1998; 7:143-148.}