NursingKnowledge:2015UpdatesfromBigDataProjects

10:45Hindsight:WhereWeHaveBeen,WhatHaveWe
Accomplished
MeasuringNursingValue
JudithJ.Warren,PhD,RN,FAAN,FACMI;
NancyDunton,PhD,FAAN;
EllenHarper,DNP,MBA,RN-BC, FAAN;
JohnWelton,PhD,RN
SkiUMahRoomGreen

NursingKnowledge:2015UpdatesfromBigDataProjects
Project 3/ Name: Advancing the NDNQI Pressure Ulcer eMeasure work

Monitor HL7 and S&I Framework to determine the part of their work that applies to the
Pressure Ulcer eMeasure work
Support the ANA in the political work of insuring the adoption of the Pressure Ulcer
eMeasure for Meaningful Use at ONC, CMS and NQF
Encourage vendors and EHR users to implement the Pressure Ulcer eMeasure
Participate in leveraging this work in other health policy arenas.

Team Leaders:

Judith J. Warren, PhD, RN, FAAN, FACMI; Professor Emeritus, University of Kansas
School of Nursing and Warren Associates, LLC
Nancy Dunton, PhD, FAAN; Professor, University of Kansas School of Nursing,
Director of NDNQI

Members:
Cheryl Peterson
Ellen Harper
Catherine ivory
Tess Settergren

Members
Roy Simpson
Sandra Bergquist-Beringer
Denise Downing Janet Cuddigan
Gail Latimer
Carolyn Aydin
Lillee Gelinas
Harriet Aronow

Sue Lundquist
Nikolas Matthes
Nell Buhlman

Accomplishments:
1. Sandra Bergquist-Beringer was a member of the technical expert panel for this pressure
ulcer measure in post-acute care. Information to calculate the measure is already in
CMS's LTCH, IRF, and MDS datasets.
2. Warren, J.J. & Dunton, N. (2015). eMeasure Development Process Exemplar. Silver
Springs, MD: American Nurses Association.
3. Judith Warren presented Nursing Data to Support the C-CDA, eMeasures, and Big Data
Science - Ready or Not? AMIA 2014 Fall Symposium. Sponsor: American Medical
Informatics Association, Washington, .DC, November 18, 2014
4. Judith Warren presented Navigating Meaningful use: What It Means for Your Practice.
American Nurses Association Webinar, June 18, 2014.
5. Sandra Bergquist-Beringer, Judith Warren, Don Eyberg; Brandon Crosser, Rosemary
Kennedy, Chanawee Prinyarux, Betsy Wagner, Nancy Dunton, presented The
Reliability of the NDNQI Pressure Ulcer eMeasure A Pilot Study at the 2015
Midwest Nursing Research Society conference.
6. Catherine Ivory and Ellen Harper appointed to the technical Expert Panel (TEP) for the
Value Set Harmonization Project

NursingKnowledge:2015UpdatesfromBigDataProjects
7. Susan McBride represented ANA at the eMeasure Kaizen in December 2014.
8. Laura Heermann and Greg Alexander appointed to the NQF HIT Safety subcommittee9. Susan McBride serves on the ONC Safety Center WG.
10. Susan McBride and Maureen Daley were appointed to the CMS Hospital Structural and
Process Measure eCQM TEP
11. Kelly Cochran now leads the ONC Nurse Appointee Group.
12. Judith Warren attended the QDM and VASC User Group meetings.
13. Rosemary Kennedy attended the HL7 meetings.
14. Additional resources can be found at http://z.umn.edu/bigdata Click on Agenda and
specific handouts
Future Recommendations:
1. ANA should continue to support the recognition of the Pressure Ulcer eMeasure by NQF
and the adoption of it by CMS.
2. ANA and Press Ganey Associates should collaborate with NPUAP to insure a
standardized dataset for documenting pressure ulcer care so that eMeasures may be
calculated for
a. All care settings
b. The identification of the nursing unit where the care is delivered
c. Pressure Ulcer prevention
3. This work should be incorporated into the Big Data Project 7 group working on the Value
of Nursing.
4. Local care organizations should be encouraged to develop data centers/repositories for
the storage of eMeasure data and information.

Nursing Knowledge: 2015 Updates from Big Data Projects

PROJECT # 7 GROUP
DEVELOP STRATEGIES TO MEASURE THE VALUE OF NURSING
GROUP OBJECTIVES:
1. Develop a national consensus data model to measure patient level nursing intensity, patient level outcomes and
costs per patient in multiple care settings to support the continuum of care and to produce objective measures of
nursing value.
2. Develop new nursing business intelligence and analytic tools that will utilize the rich clinical, operational, financial,
and quality/safety outcome data currently available to measure and compare nursing value.
3. Develop and test new nursing financial models to bring transparency to support the risk sharing within Accountable
Care Organizations (ACO), Value Based Purchasing, and pay for performance models.

GROUP MEMBERSHIP:

Group Leaders
Ellen Harper, DNP, RN-BC, MBA, FAAN, Vice President, Chief Nursing Officer-Premier West, Cerner Corporation,
Kansas City, MO
John Welton, PhD, RN, FAAN, Professor & Senior Scientist Health Systems Research, University of Colorado College of
Nursing, Aurora, CO
Group Members
Barbara Caspers, MS, RN, PHN, Healthcare Management Consultant, Barbara Caspers Associates, Minneapolis, MN
Lynn Choromanski, PhD, RN-BC, Health Informatics Specialist, MVNA, Minneapolis, MN
Jane Englebright, PhD, RN, CENP, FAAN, Chief Nurse Executive, Patient Safety Officer and Vice President, HCA,
Nashville, TN
Amy Garcia, RN, MSN, CAE, Chief Nursing Officer for Clairvia Workforce and Operations, Cerner Corporation, Kansas
City, MO
Cathy Ivory, PhD, RN-BC, Assistant Professor, Vanderbilt University School of Nursing, Nashville, TN
Erin D. Maughan, PhD, MS, RN, APHN-BC, Director of Research, National Association of School Nurses, Silver Spring,
MD
Peter McMenamin, PhD, Senior Policy Fellow & Health Economist, American Nurses Association, Silver Spring, MD
Beth Meyers, RN, MS, CNOR , Nurse Executive, Healthcare Analytics Strategy Director, Infor, Minneapolis, MN
Karen A. Monsen, PhD, RN, FAAN, Associate Professor, Co-Director, Center for Nursing Informatics, University of
Minnesota School of Nursing, Minneapolis, MN
Lisa Moon, RN, BSN, Director of Privacy, Security and HIE Oversight Programs, Office of Health Information
Technology, Health Policy Division, Minnesota Department of Health, Saint Paul, MN
Sharon Pappas, PhD, RN, FAAN, Chief Nurse Executive, Centura Health, and Chief Nursing Officer, Porter Adventist
Hospital, Denver, CO
Martha Sylvia, PhD, MBA, RN, Assistant Professor, Johns Hopkins University School of Nursing, Director, Population
Health Analytics Core, Johns Hopkins HealthCare, Baltimore, MD.

Nursing Knowledge: 2015 Big Data Science Conference, June 4-5, 2015 Group 7 Handout

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Guests
Carol Bickford, PhD, RN-BC, CPHIMS, FAAN , Senior Policy Advisor, Department of Nursing Practice & Work
Environment , American Nurses Association, Silver Spring, MD (consultant to the expert panel)
Kelly Morrow, RN, MSN, PhD student, University of Colorado College of Nursing, Denver, CO
Kari Miller, DNP, RN, PHN, Clinical Informatics Lead, Plan of Care Product Owner, Optum, Eden Prairie, MN
(consultant to the expert panel)
Cheryl A. Peterson, MSN, RN, Senior Director, Nursing Programs, American Nurses Association, Silver Spring, MD
Special thanks to Helen Foster, Cerner Corporation, Kansas City, MO, for her administrative assistance and support of
the expert panel.

GROUP PARTICIPATION

Group membership - 14 with 2 consultants to the group

Conference calls 14 (1.5 hours each) or 21 hours of conference calls
Total hours of participation - 162 hours total group interaction

Members
Conference calls
Conference hours
Hours of participation
Median members on call
Percent participation

14
14
21
162
7
55.1%

ACCOMPLISHMENTS
Articles Published:
Welton, J.M., Harper, E.M. (2015) Nursing value-based financial models, Nursing Economics. 33(1), 14-19.
Pappas, S., Welton, J.M. (In Press) Nursing: Key to Health Care Value, Voice of Nursing Leadership
Welton, J.M., & Harper, E.M. (pending) Developing Strategies to Measure the Value of Nursing
Harper, E.M., & Caspers, B.A. (pending) Nursing Operations-Using Technology as a Strategic Enabler
Presentations:
Presentation, John Welton, at American Organization of Nurse Executives (AONE) annual conference, Phoenix
AZ: April 2015
Presentation, John Welton, at Western Institute for Nursing (WIN) annual conference, Albuquerque, NM: April
2015
Presentation, John Welton, at American Medical Informatics Association, Washington DC: November 2014.

FUTURE RECOMMENDATIONS
Dissemination
ANA Staffing and Quality Conference (March 2016) abstract submitted
NI2016 pending abstract submission and preconference workshop in Switzerland in collaboration with
Michael Simon University of Basel, Suisse.
Editorial in International Journal of Nursing Studies follow up from conference
Abstract submitted for Spring 2016 ANA Nurse Staffing and Quality conference

Nursing Knowledge: 2015 Big Data Science Conference, June 4-5, 2015 Group 7 Handout

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Research

Pending pilot testing of common data model with actual acute care data
AHRQ/NINR potential submissions for extramural funding

Collaboration:
Seek funding for interdisciplinary meeting with HFMA and non-nursing healthcare finance and policy
community.
Collaborate with the Nursing Management Minimum Data Set (NMMDS) team to align the nursing value
model with the NMMDS.

DELIVERABLES
1
2
3

Item
Identify nursing current and future value based metrics
Develop a conceptual data model for measuring nursing value
Create a common data dictionary to describe patient, nurse, and system level data
elements to be extracted from existing data sets to populate the conceptual model
to measure nursing value
Create new nursing business intelligence tools and analytics that will utilize the
common data elements to benchmark, compare, and trend nursing value

Nursing Knowledge: 2015 Big Data Science Conference, June 4-5, 2015 Group 7 Handout

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Table 1 Value-Based Metrics

Dimension

Traditional Model

Proposed Value-Based Model

2

Costing
(Direct and
1
Indirect Care)

Nursing Costs per Patient Day (NCPPD);

Nursing Costs per visit (home health);
Nursing Costs per Patients Seen (ER, clinic)

Direct Nursing Costs per Patient per Day (DNCPPD)

Indirect Nursing Costs per Patient Day (INCPPD) as the amount
of indirect costs such as vacation, education, management,
etc., allocated proportionally to each patient

Costing
(All Costs)

Sum of all nursing labor costs within a cost

2
center by budget period

Intensity

Nursing Hours per Patient Day (NHPPD)

Billing

Daily Room Rate

Nursing Acuity
Reimbursement
and DRG

Analytics

Unit of Analysis

Note: TBD

No direct reimbursement for nursing

care
Average room costs across all patients
as static DRG cost weight
Average nurse staffing levels (ratios)
NHPPD/NCPPD
Case Mix Index (CMI)
Unit, hospital (many nurses, many
patients)
Month or year

Cost Center: Sum of DNCPPD and INCPPD by budget

period within a cost center.
Patient: Actual DNCPPD + proportional INDPPD by case,
e.g. sum for entire hospitalization, sum for series of home
visits, etc.

Direct Nursing Hours per Patient per Patient Day (DNHPPD)

Indirect Nursing Hours per Patient Day (INDPPD)
Unbundled Nursing Hours and Costs per Patient per Day
Note: TBD
Separate nursing cost/revenue center, nursing service line

Nursing intensity weight for DRG

Average direct and indirect nursing intensity (time) and

costs per patient per case
Nursing Case Mix Index (NCMI)
Nursing Acuity Adjusted Hours/Costs NAAH/HAAC
Patient, nurse (individual nurses linked to each patient)
Real-Time aggregated by time slice as appropriate

Statistics

Mean NHPPD/NCPPD (or nurse-patient

ratios), e.g. NDNQI quarterly cross unit
comparisons

Multilevel regression by patient, nurse, DRG

Quality

Retrospective aggregate level rates, e.g.

falls rate by month/quarter

Mean unit level productivity measures,

e.g. productive /nonproductive hours % by
unit or cost center

Performance

No known measures

Encounter
4
(Assignment)

Based on average nurse to patient

ratios

Metrics include:
o Average nurse: patient ratios
or NHPPD, nursing hours per
home visit, nursing hours per
member per month (primary
care), etc.

Productivity

Nursing Knowledge: 2015 Big Data Science Conference, June 4-5, 2015 Group 7 Handout

Patient level quality metrics tied to actual care hours

(intensity) and costs, e.g. additional nursing and hospital
costs of a fall or infection (retrospective)
Prospective predictive analytics of probability of adverse
occurring for an individual patient based nursing acuity,
patient demographics, or other patient, nurse, and unit
factors
Individual nurse/staff productivity (direct care hours /
total hours)
Unit level aggregate productivity
Individual/unit productivity metrics, e.g. patient level pain
assessment and PRN use of narcotics; medication
administration delays and omissions, etc.
Based on individual patient acuity and nurse experience
and acuity adjusted workload
Metrics include:
o Average patient level demand for nursing care vs
actual hours delivered per patient
Patient level aggregate analysis including by day of stay;
summary by DRG/DX; summary patient level data by unit
or cost center

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1.

2.
3.
4.

Direct care nursing costs are identifiable as those costs (and time) directly associated with a particular patient. Indirect care
costs are those that are not associated with direct care, such as vacation or sick time, nurse managers, in-service education, etc.
Costs per patient day can be allocated as per visit, cost per member per month or other appropriate patient level metric that is
setting specific.
NHPPD/NCPPD subsumes both direct care and indirect care costs and time and typically are not unbundled.
Patient level acuity measures are diverse and setting specific (e.g. acute care vs. home health). Need further language to
develop this into value-based nursing care.
The Nurse-Patient encounter can be any relationship between a nurse and patient, for example an assignment in a hospital
setting, a home healthcare visit, an interaction with a student in a school based clinic, etc.

Table 2 Value-Based Analytics

Metric
Staffing Levels

Traditional Model
Unit level analysis of hours and costs by skill
mix, e.g. %RN vs UAP

Outcomes

Hospital and unit level outcomes, e.g. average

length of stay

Trending

Trend of unit average cost per patient day by

month or quarter

Nurse Characteristics

Unit or department level average nurse

experience and academic preparation by
budget period (e.g. month, quarter)

Nursing Acuity

Unit level average metrics by month or quarter

Workload

Nurse to patient ratios or average NHPPD

Outliers

Unit level average length of stay, NHPPD or

NCPPD
Average total nursing costs per patient day
(many patients and many nurses)

Nursing Costs

Nursing Knowledge: 2015 Big Data Science Conference, June 4-5, 2015 Group 7 Handout

Proposed Value-Based Model

Patient level analysis of direct care hours by nursing skill
mix, effects of individual nurse and nurse characteristics
(e.g. experience level or AD vs BSN) on patient outcomes
of care
Patient level outcomes analysis e.g. unit and hospital
length of stay adjusted by nursing acuity or tied to
DRG/DX, change in shift level nursing outcomes.
Trend of patient level direct costs per patient day (direct)
by month, day of stay, DRG, etc.
Patient level measures of average experience level and
academic preparation of nurses assigned to patient
aggregated by day of stay, summary for hospitalization,
trend by shift, etc. These can be rolled up into an episode
of care, e.g. hospitalization, series of home visits, etc.
Patient level acuity by day of stay, aggregate metrics by
shift, month, day/evening, quarter, etc. As well as
patient level acuity trends (patient) or aggregate unit
level trending analysis. Patient level acuity by discharge
or DRG
Acuity adjusted assignments and efficiency measures,
e.g. relationship between actual patient level hours
needed vs. delivered
Patient level length of stay, direct nursing care hours and
costs
Patient level nursing costs per day per patient; nursing
wage variability by patient;

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Green = costs; Blue = patient; Purple = nurse/provider; Red = facility/business entity

Nursing Value Generic rev30

Nursing Common Data Model

PK

PK

Nurse_Credential

Nurse_Patient_Encounter

Patient
Provider

ID_Patient

PK

ID_Encounter

PK

Age
Race
Sex
OtherDemographics

FK3
FK2

ID_Episode
ID_Nurse
DayTime_Start
DayTime_End
Shift
Type

FK1

Provider_ID
System_ID
Place of Service

PtProblem

Episode

PK

ID_Episode

FK2
FK3

ID_Patient
Provider_ID
EpisodeType
DateAdmit
DateDischarged
AdmissionSource
DischargeDispition
DRG
APRDRG
Payer
ProcedureCode(1-15)
Primary DX
Secondary DX (2-15)
Readm<30d

ID_Episode

FK2

ChargeID
ChargeItem
Units
Charge

ID_Nurse
Credential_Type
DateAwarded
DateExpire

Nurse
FlowSheetData

PK

ID_PtProblem

FK1
FK2
FK3

ID_Nurse
ID_Episode
ID_FlowSheetData
ProblemIdentDateTime
ProblemItem
ProblemDesc
ProbResolutionDate

PK

Intervention

PK

ID_Intervention

FK1

ID_Episode
InterventionDayTime
InterventionCode
InterventionClass

ID_Outcome

FK1
FK2

ID_Episode
ID_FlowSheetData
OutcomeDayTime
OutcomeItem
OutcomeScore

ID_Nurse

FK1

ID_Unit
DOB
Race
Sex
JobClass
DateRN
DateHire
DateSeparated
Wage
Highest Degree
Assigned Unit
FTE
Agency
NPI

EncounterCost
PK

ID_EncounterCost

FK1

ID_Encounter
DirectCareHours
DirectCareCost
NurseWage
ShiftDifferential
OtherShiftCosts

Outcomes
PK

PK
ID_FlowSheetData
FlowSheetDateTime
ItemLabel
ItemValue

Charges
PK,FK1

ID_Credential

Nurse_Certifications
PK

ID_Certification

FK1

ID_Nurse
CertificationType
DateStart
DateExpire

ChargeMaster
PK

UnitBudget

ChargeID
Charge Description
Charge

PtLocation
PK

ID_PtLocation

FK1
FK2

ID_Episode
ID_Unit
Unit_ID
UnitDescription
PatientLocationOrBed
DayTimeStart
DayTimeEnd
Admit (y/n)
Discharge (y/n)

ChargeCost
PK

ChargeCost_ID

FK1
FK2
FK3

ChargeID
ID_CostItem
ID_EncounterCost
BudgetPeriod
IndirectCareCostAverage
PatientNursingCost

PK

Unit

PK

ID_UnitBudget

ID_Unit

FK1

ID_Unit
BudgetPeriod
RN_salaries
RN_hours
NurAide_hours
NurAide_salaries
Other_hours
Other_salaries
RN_FThires
RN_FTterminate
RN_BudgetedFTE
NurAide_BudgetFTE
TotalPatientDays

UnitName
UnitType
NDNQI class
Beds

CostItem
PK

ID_CostItem

FK1
FK2

ID_UnitBudget
ID_EncounterCost
TotalHours
TotalCosts
SumDirecCareCosts
IndirectCareHours
IndirectCareCosts
IndirectCareCostAverage
Benefit Costs

Copyright notice: This work is provided free of copyright and in the public domain

Nursing Knowledge: 2015 Big Data Science Conference, June 4-5, 2015 Group 7 Handout

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