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Slide 1
NACNS Cost Analysis Toolkit-
a Business Guide for the CNS
Anita White MSN, RN, ACNS-BC, CCRN
Deborah Messecar PhD, MPH, AGCNS-BC, RN
Stacy Jepsen MSN, RN, ACNS-BC, CCRN
Jerithea Tidwell RN, PhD, PNPBC, PCNSBC
Yvonne Dobbenga-Rhodes MS, RNC-OB, RNC-NIC, CNS, CNS-BC, CPN
NACNS Practice Committee Presentation
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Slide 2
2017 NACNS Cost Analysis Toolkit
No speakers have claimed any conflict of interest.
No commercial support or sponsorship has been received
for this activity.
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Slide 3
Objectives
The CNS will be able to:
Replicate tools related to cost of a project
Critique literature related to CNS role and cost
reduction and quality improvement
Critically analyze frequently asked questions from
the NACNS list serve and survey on cost
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Slide 4 Anita White (Chair) MSN, APRN, ACNS-BC, CCRN Clinical Nurse Specialist MICUCleveland ClinicCleveland, [email protected]
Yvonne Dobbenga-Rhodes (Board Liaison) MS, RNC-OB, RNC-NIC, CNS, CNS-BC, CPNMaternal-Child Health Clinical Nurse SpecialistWashington Hospital Healthcare SystemFremont, [email protected]
Sarah Barry RN, CNS-BC Southern Coos Hospital Brandon, [email protected]
Martha J. Biddle PhD, APRN, CCNSAssistant ProfessorUniversity of Kentucky Lexington, [email protected]
NACNS Practice Committee 2016-2017
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Slide 5
Tamera Brown MS, RN, ACNS-BC, CWOCNIndiana University Health Ball Memorial HospitalSpringport, [email protected]
Stacy Jepsen MSN, APRN, ACNS-BC, CCRNClinical Nurse Specialist, Med/Surg/Neuro Critical CareAbbott Northwestern [email protected]
Deborah Messecar, PhD, MPH, AGCNS-BC, RNAssociate ProfessorOregon Health & Science University Portland, [email protected]
Patricia Rosier, MS, RN, ACNS-BC Surgical Clinical Nurse Specialist Berkshire Medical Center Pittsfield, [email protected]
Jerithea Tidwell RN PhD, PNP-BC, PCNS-BCNICU Clinical Nurse SpecialistChildren's Medical Center – DallasDallas, [email protected]
NACNS Practice Committee 2016-2017
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Slide 6
Special Recognition to:
The 2014 Cost and Outcomes Taskforce:
Ginger Pierson, Anne Muller, Pat Gilman, Bobbi Leeper,
Sonya Flanders, Kim Daniels, Pamela Mittlestadt.
Melinda Ray and NACNS staff- Jason Harbonic, Courtney
Cook, and Laura Heustis
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Slide 7
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Slide 8
Cost Analysis Toolkit Contents
How to Get Started
Describes a Six Sigma process to guide the CNS
in a change strategy involving cost analysis
Define, measure, analyze, design, verify
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Slide 9
Cost Analysis Toolkit Contents
NACNS Crosswalk
Extensive table of resources: All About Project Management,
The Society of Cardiovascular Care, The W.Edwards Deming
Institute®, Project Management Skills, iSixSigma, Gantt Charts,
Mind Tools, Human Factors International, Toptal, Percentage
Mathematical Calculators, and Skills You Need.
Contains embedded links, enabling the CNS to have direct
access to the resources
Literature table: extensive literature review of CNS work cost
analysis, with review and grading of each article.
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Slide 10
Cost Analysis Toolkit Contents
Frequently Asked Questions
Series of frequently asked questions from the
NACNS list serv and the CNS Cost Analysis
Survey.
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Slide 11
The CNS & the Business of
HealthcareAnita White MSN, RN, ACNS-BC, CCRN
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Slide 12
Paradigm Shift
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Slide 13
The Value Imperative
Volume → Cost
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Slide 14
What Drives Value?
Unsustained Costs
Varied Quality Outcomes
Transparency
Dissatisfaction
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Slide 15
How Does this Affect the CNS?
CNS & Quality of Care
CNS & Outcomes of Care
CNS & Cost?
Do I now need an MBA?
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Slide 16
Cost Avoidance?
Source Outcomes
Agency for Healthcare
Research and quality
Adverse Drug Events, Disease Specific (asthma,
COPD, Cancer, CAUTI, CLABSI, Falls, Heart
Disease, Hospital Acquired Pressure Injury, OB
adverse events, postop venous
thromboembolism, surgical site infections,
treatment of mental disorders, treatment of
trauma-related disorders, ventilator-associated
pneumonia)
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Slide 17
Cost Avoidance
Source Outcomes
OSHA Safety Pays Program
Estimator
ANA’s Handle with Care
Program
Employee musculoskeletal injuries,
Employee needle sticks,
Robert Wood Johnson
Foundation
Individual State Board of
Nursing
RN Turnover
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Slide 18
Cost Analysis Strategies
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Slide 19
Cost Analysis Strategies
Toptal
https://www.toptal.c
om/freelance/don-t-
be-fooled-the-real-
cost-of-employees-
and-consultants
Fee Yes-Online
Calculator
Employee
versus
Consultant
Employee Cost
Calculator:
‘ Don't Be Fooled:
Calculate the Real
Cost of Employees
and Consultants’
No Yes-minimal Yes Yes-online
calculator
Yes-online calculator
and article
Percentage Change Math
Calculators
http://percentagecal
culator.mes.fm/
https://percentageca
lculator.net/
Free Yes-online
Calculator
for
mathematica
l calculation
of percent
difference
Useful, accurate, for
quick calculations
No No Minimal-
intuitive
calculator
Yes-online
calculator
Yes-online calculator
Skills you need site
http://www.skillsyou
need.com/num/perc
ent-change.html
Free Yes-online
calculator for
mathematica
l calculation
of percent
difference
How to calculate
percent increase and
percent decrease.
No No Yes-intuitive
calculator,
examples and
equations
Yes-online
calculator
Yes-online calculator
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Slide 20
Cost Analysis
Pre/post implementation analysis
Cost Avoidance/cost reduction
Communication of cost savings
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Slide 21
Formulas for Cost Analysis, Benefit-
cost Ratio, Return on Investment
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Slide 22
ExamplesAssumptions:
Total Cost for procedure= $4.24
Total Cost for equipment requested= $20,000
Anticipate 42% decrease in number of procedures
Anticipate 26% greater chance of successful procedure
Projected Total Cost to treat CAUTII== $7,000
Training Cost/class $475
14 participants @ $40/hour x3 hours 1,680
$2,155
What does the
evidence say?
What is the
actual cost?
What is the cost
of a CAUTI?
What is the training
cost?
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Slide 23 Examples- Disclaimer…the numbers below are not
reflective of the actual math.
Cost of 1CAUTI 0.85 Benefit to Cost Ratio <1 = negative
impact
Cost of 72 CAUTIs (ICU 2016) $ 1,326,000= 5.1 Benefit -Cost Ratio
>1=positive
impact
Cost of equipment $260,000
Add in cost to train nurses:
Cost of 72 CAUTII (ICU 2016) $1,326,000=4.22 Benefit to Cost Ratio
>1 = Positive impact for ROI
Cost of equipment & 22 classes $313,875
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Slide 24
Resources/Tools Related to Project
Management
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Slide 25
Tools Related to Process Changes
Tools…necessary component to identify areas for improvement
Project Management
The Scientific Method
Business Charter
Flow Chart
Algorithm
Mapping
Concept Analysis
Fishbone Diagram
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Slide 26
The Scientific Method
Plan
Do
Act
Study
Plan Who, what, when, where, how
Do Carry out the plan
Study What was learned?
Act What changes to be made?
Next Goal/Cycle?
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Slide 27
Types of Tools & Use
Charter
Business terms: formal structure to program/ project
Define intent of project
Make for each key point in the review process and use this to
include the PDSA cycle
Identify Barriers/Solutions
Basic components:
Goal statement, project flow timeline, project scope.
committee members
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Slide 28
Basic Process Structure Tools
Algorithm:
Look at process and determine what is acceptable.
Flow Chart:
Each symbol has meaning connections identified.
Mapping:
Each symbol has meaning and each symbol has
connections identified yet this type is more detailed
than flow chart.
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Slide 29
Flow Charts
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Slide 30
Flow Charting People
Controlling Process
Improvement
1. Rectangle, designating an activity or activities.
2. Diamond, designating a binary decision.
3. Circle, designating an on-page reference.
4. Five-sided “home plate,” designating an off-page reference.
5. Oval, designating the start or end of a process.
6. → Arrow, connects symbols and indicates directionality.
7. Delay, designating a delay in the process.
8. Document, designating a document created in the process.
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Slide 31
By FabianLange at de.wikipedia [GFDL
(http://www.gnu.org/copyleft/fdl.html)], via Wikimedia
Commons
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Slide 32
Communication of Success
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Slide 33
PROJECT COMMUNICATIONS
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Slide 34
Communication…just the basics
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Slide 35
How Much is Enough?
50-60% reduction of
monitor alarms in our
ICUs
Alarms were reduced
from over 8 million
per month per 264
beds to a little over 2
million per month per
264 beds.
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Slide 36 Change Agents: Anita White CNS-Chair ICU Alarm
Committee-reduced alarms in all ICU settings by over 60%
by standardizing alarms. Millions of alarms gone.
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Slide 37
Pay Attention to Details!
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Lift Pad Bath Blanket
Developed Skin Breakdown 28.50% 13.60%
Experienced No Skin Breakdown 71.40% 86.30%
Percentage
The Tower Study Regional Medical Center
February 14 to February 21, 2005 ICU and CCU Combined Results
N=36Lift Pad Skin Breakdown: N=4/14 No Breakdown N=10/14
Bath Blanket Skin Breakdown: N=3/22. No Breakdown N=19/22
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Slide 38
Choosing how to communicate
Paper
Electronic
Meetings
One on one discussions
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Slide 39
Team problem-solving guidelines
Define the problem
Analyze the problem
Develop solutions to consider
Choose a solution
Implement action plan
Evaluate and adjust
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Slide 40
Crosswalk-Evidence Based Practice
OverviewDeborah Messecar PhD, MPH, AGCNS-BC, RN
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Slide 41
Search strategy- Database: Ovid MEDLINE(R)
<1946 to October Week 1 2016>1 Nurse Clinicians/ec [Economics] (185)
2 limit 1 to english language (182)
3 exp Nurse Clinicians/ (7770)
4 exp "Costs and Cost Analysis"/ (203170)
5 3 and 4 (312)
6 limit 5 to english language (309)
7 1 or 6 (414)
8 ((clinical nurse special* or nurse clinician*) adj7 (cost* or expendit* or financ* or dollar* or econom*)).mp.
[mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary concept word, unique identifier] (41)
9 limit 8 to english language (41)
10 7 or 9 (434)
11 exp Nurse Clinicians/ (7770)
12 ec.fs. (374020)
13 11 and 12 (366)
14 limit 13 to english language (360)
15 10 or 14 (520)
16 limit 15 to yr="2006 - 2016" (147)
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Slide 42 Search Strategy-Continued
OVID search strategy was replicate in CINAHL
And in EBM database: NHS Economic Evaluation Database
Articles were selected for inclusion if they met the following
additional criteria:
Studies or reviews were limited to those conducted on US
population
Specifically addressed CNS as part of the projects/studies
conducted
Focused on cost savings / cost avoidance
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Slide 43
Table 3: Literature Review Cost and CNS Work Articles included met all of the above search criteria
The following were addressed for each article:
Design/Purpose
Sample/Setting
Measurements/Instruments
Results
Strengths /Weaknesses
Relevance to Problem Value of CNS Interventions
Level of Evidence / Grade
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Slide 44
Articles Not Included in Literature Review
that Provide Background Information
Additional table contained articles that did not meet the criteria for
inclusion in the evidence table
These articles may have:
Been conducted outside the U.S. with “nurse specialists” who
may have been performing in a role similar to the CNS
Focused on nurse specialists in U.S. who were not CNS
Focused on reimbursement rather than cost savings
No data presented on cost savings
Offered an opinion on how the CNS could save costs
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Slide 45
Overall findings from Table 3
Cost savings have been demonstrated in several practice
settings with a range of patient populations
A number of the articles focused on integrative reviews from
smaller descriptive studies
Several studies focused on transitional care and or reducing
more expensive types of care
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Slide 46
How to use table to assess evidence for
your practice
First, review table for articles pertinent to clinical setting and problem
Each article has enough detail so that you should be able to determine its applicability to your issue/concern
For each article, look at the level of evidence that is noted in the last column – this helps you judge the quality of what is presented
In addition, for each article
Identify important findings
Identify flaws from your perspective
What are the limitations of the match to the issue/concern
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Slide 47
Next step
After identifying relevant articles and retrieving and reviewing them for your setting
Consider contacting the authors in you need more information (contact information should be provided in each article)
Look for tools or approaches outlined in the rest of the tool kit that might be relevant
Collaborate with team colleagues to plan an approach
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Slide 48
How Do I Start?
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Slide 49
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Slide 50
How Do I Start?
Let’s look at the steps…
Six Sigma Process approach
Define
Measure
Analyze
Design
Verify
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Slide 51
Define Your Problem
#1 Technology Hazard
Excessive Alarms may lead to Alarm Fatigue
May Ignore or Disable Alarm
Potential to IMPACT Patient
Safety.
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Slide 52
Build The Case-Who are your Key
Stakeholders?
CNS
Frontline
Nurse
Accreditation
Nursing
Director
Data
Pull
Physician
Champion
Quality
Nurse
Manager
Clinical
Engineering
RT
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Slide 53
Stakeholders Prioritization Grid
Power
High →
Low Power →
Interest
Keep Satisfied
Manage Closely
Monitor
Keep Informed
http://www.mindtools.com/subscribe.htm
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Slide 54
Begin to Assess Your Unit/Hospital’s
System
Appropriateness of monitoring
Current state
Staff education and competency
Staff attitudes / perceptions
Survey
Patient outcomes
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Slide 55
Perform Gap Analysis
“Your Project” current state
Unit Gap Analysis
Gather data from clinical engineering /
facilities
# / defined time
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Slide 56
Patient Data
Review Patient outcomes
Organizational data on “your topic”
Do you have data retrieval systems:
manufacturer or your own system on data
retrieved
Patient event data?
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Slide 57
Pre-Change Data Measurement
Alarm Event Data-Coordination with Facility/IT
Rapid Response Team/Code Team Event
Adverse Events
HCAPS
Other Hospital databases
National standards
Pre-Change Assessment
Survey staff on perceptions / attitudes
Staff knowledge monitoring practices
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Slide 58
Measure Metrics
Consider:
Event data such as clinical alarms
safety
staff education/competencies,
surveys/perceptions
patient outcomes
Resource: Crosswalk
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Slide 59
Analyze
Identify goals: determine how process changes will affect process results.
Analyze Data from Measure section
Was there a Frequency increase or decrease?
What did the increase or decrease?
Were there other factors that led to the increase or decrease?
Did patient compromise occur?
Evaluate / Prioritize areas for improvement
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Slide 60
Develop a Plan Overview
Identify stakeholders
Define outcomes
Can the solution be standardized?
Accountability at the bedside
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Slide 61
Design
Work out details of change to be implemented
What to change /process to implement
Include nurse related needs for pilot
Staff education
Competencies
Include dates/times to monitor data
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Slide 62 Develop Strategies for Management of
the Projected Change
Customization
Evidence based use
Clarify accountability
Policy development
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Slide 63
Design Resource
Work out the details for the change
Identify strategies for the problem to be managed
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Slide 64
Verify
PDSA Cycle on pilot units
Outcomes:
Evaluate goals for success
Overall # of alarms
% nurses customizing alarms
% of high, medium, low, and technical alarms
Survey staff on perceptions / attitudes
Pilot Study Units to monitor change
Implement changes
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Slide 65
Frequently Asked QuestionsStacey Jepsen MSN, APRN, ACNS-BC, CCRN
Jerithea Tidwell RN, PhD, PNP-BC, PCNS-BC
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Slide 66
229 responses
Classification
Critical Care
Medical Surgical
Other
Cost Analysis Tool-kit Data: Who..
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Slide 67
Cost Analysis Tool-kit Data: Who..
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Slide 68 Cost Analysis Tool-kit Data: What they want to
know…
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Slide 69 Cost Analysis Tool-kit Data: What they want
to know….
Opportunities for CNS Education
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Slide 70
Cost Analysis Toolkit FAQ
What are the differences between variable and fixed cost?
Total cost = sum of both fixed and variable costs.
Variable costs are items that change as the quantity of
services increase (supplies, direct patient care labor).
Fixed costs occur no matter the quantity of service provided
(heating, lights, building lease/rent).
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Slide 71
What are the differences between
variable and fixed cost?
CNS work can greatly impact the reduction of
variable cost which can lead to a total cost of
care reduction, such as reduction in the number
of x-rays done to verify tube feeding tip location.
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Slide 72 Cost Analysis Toolkit FAQ
What are some of the ways to communicate cost savings?
Cost avoidance can demonstrate savings. The average cost of
a hospital acquired pressure ulcer or other hospital acquired
conditions (CAUTI, CLABSI) can be listed in the saving
associated with a specific intervention/s that lead to
reduction in cases.
Cost reduction through reduction in variable or fixed costs.
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Slide 73
Cost Analysis Toolkit FAQHow can these savings be presented to larger groups?
A scorecard can display measures, associated goals, and other indicators that represent the measures performance.
Financial savings associated with each measure can also be listed.
Refer to the Cost Analysis Resource Crosswalk article titled: Using a Scorecard to Demonstrate CNS Contribution, 2015. See also Clinical Nurse Specialist Tool kit: Chapter 14 Communicating Results: Who Needs to Know What
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Slide 74
Cost Analysis Toolkit FAQ
Should every project have a cost analysis associated with it?
Having a cost an analysis for projects that you participate in
helps to quantify the work that you do in terms of dollars and
time. This can be very useful when justifying CNS role.
See Cost Analysis Resource Crosswalk Literature Review Articles titled: A Business
Case Framework for Planning Clinical Nurse Specialist--Led Interventions. & Nursing
Knowledge and Theory: Where Is the Economic Value?
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Slide 75
Cost Analysis Toolkit FAQ
Where do I find an example of an executive summary and what is it?
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Slide 76
Project Charter
Project Name: The RACE
Project Summary
Overview: What & Why
Project Goal / Business
Driv ers:
The RACE is a multidisciplinary process improvement project to improve operational performance and patient care
for Acute Care Service guided by the CNS.
Project Scope & Objectives: ACS units participate in a year-long friendly competition measuring improvement in patient satisfaction,
interdisciplinary communication, and multidisciplinary performance.
Known Deliverables: Create an incentive process aimed at improving specific nursing Sensitive Indicators, family and patient
satisfaction, nurse satisfaction and accountability.
Desired End Date:
Who: Roles & Responsibilities
Project Sponsor:
Project Manager:
Stakeholders:
Support Team Members:
Project Scope
Systems and processes that will be affected:
Systems / Processes Quality and performance metrics have been identified and organized among the four quarters. Refer to Attachment A. Each
ACS unit can create a process that improves their area’s outcomes. Processes proven beneficial may be shared among areas
in order to improve the performance of all ACS areas.
Unit process examples:
Bedside Check/Report
Staff attending rounds/huddles
RT communicates with Charge/White Boards
HUC Callbacks
Nursing M&M (Excluding Peer Review) - Initiatives developed as a result of specific events
Daisy Project
Warm Welcome
Other processes developed by individual units
Data is collected twice a month (one day shift and one night shift) on specific measures as indicated for each quarter. Data is
collected using the following:
ACS Dashboard (Statit) - Metrics determined by Dr. Sheehan, Data collection by Health Information Management
(Judith Leever)
Patient Event Log- Metrics, Data Collection by Allison Langston
EPIC Reports-Carlie Gotieb
NSI Dashboard Metrics- Metrics determined by Magnet focus, Data collection by Serena Lucas
National Patient Safety Goals- Metrics determined by Joint Commission based on serious and sentinel events
reported, Data collection by Quality Review Department
NRC Picker Data
Once data is collected, it is saved in the RACE folder on the k-drive.
Boundaries
Constraints / Dependencies: 1. Time commitment with manual audits.
2. The monthly report will be compiled by the CNS’s and presented to the committee at the monthly RACE meetings.
3. The educators will identify one focus area per month based on the audit results and conduct an analysis
Executive Summary/Project Charter
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Slide 77
Cost Analysis Toolkit FAQ My employer would like for me to design a plan for disseminating
latest research findings to our staff. How do I start? Refer to the article ‘The Impact of Clinical Nurse Specialists on Clinical Pathways in the
Application of EBP, 2010’ in Table 3: Literature Review Cost and CNS Work of the NACNS Cost Analysis Toolkit
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Slide 78 Several of the leadership position list MBA as being preferred;
How do CNS indicate their unique leadership and budget skills in
the absence of having a MBA?
This depends on the position you are seeking.
CNSs have a unique set of skills that can allow versatility in role
i.e. Director of Infection control; Director of Quality, Director of
Professional Development or Director of Magnet.
Refer to the Cost Analysis Resource Crosswalk article titled: Impact on the Clinical Nurse
Specialist Role on the Cost and Quality of Healthcare
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Slide 79
Continued…
One might invest in acquiring the Nurse Executive or
Advanced Nurse Executive certification. This exam It
captures Human Capital Management, Fiscal
Planning, Execution and Accountability and basic
budgeting and accounting principles.
http://nursecredentialing.org/NurseExecutive-
Advanced
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Slide 80 What initial steps do I need to take to bill for my
services? How can I associate fees to services
provided by a CNS?
Investigate credentialing process in your organization. See Clinical
Nurse Specialist Toolkit: A Guide for the New Clinical Nurse Specialist;
Chapter 19 “Navigating the Privileging and Credentialing Process”
Apply for NPI number https://nppes.cms.hhs.gov/NPPES/Welcome.do
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Slide 81
Continued…
Explore requirements for prescriptive authority as a CNS in
your state. Some states require courses/documentation of
clinical hours.
Collaborate with billing specialist and/or administrative
leaders in Advance Practice Service in your organization to
learn about criteria for payment, appropriate documentation
of patient encounters, levels of service, and requirements of a
CPT code.
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Slide 82
Continued…Seek out billing training courses
Consider what billable service(s), procedure(s), education you provide (i.e. diabetes education, complex patient coordination, Advanced WOCN)
Market /create CNS consult in EMR system for service(s) provided
Track /monitor patient encounters (include time in minutes) See Clinical Nurse Specialist Toolkit : A Guide for the New Clinical Nurse Specialist; Chapter 20
See Cost Analysis Resource Crosswalk articles titled : Introduction to Reimbursement of Advanced Practice Registered Nurse Services and Understanding Medicare Part B Incident to Billing; Reimbursement of Advanced Practice Registered Nurse Services: a fact sheet & PRESIDENT SIGNS BILLS REPEALING SGR FORMULA AND INCREASING CNSs' ABILITY TO ORDER MEDICARE SERVICES...Sustainable Growth Rate
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Slide 83
Questions & Answers?
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Slide 84
Thank You!
NACNS Practice Committee
References available on toolkit
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