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2015 HSR&D/QUERI National Conference Abstract

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3041 — Implementation of the Veterans Health Administration Staffing Methodology Directive in Acute Care Medical Centers: A National Qualitative Project

Robinson CH, VA Center for Clinical Management Research; Forman JH, VA Center for Clinical Management Research; Yankey N, VA Center for Clinical Management Research; Annis A, VA Center for Clinical Management Research; Krein SL, VA Center for Clinical Management Research, University of Michigan School of Nursing and Department of Internal Medicine; Sales A, VA Center for Clinical Management Research, University of Michigan School of Nursing;

Objectives:
In 2010, the Veterans Health Administration (VHA) promulgated a Staffing Methodology (SM) directive for inpatient nursing units, which is both a staffing and budget forecasting tool. In partnership with the Office of Nursing Services, we assessed implementation of the directive in a nationwide quality improvement project.

Methods:
We conducted semi-structured telephone interviews with Nurse Executives and their teams at 21 purposively selected acute care medical centers. Interviews took place from March - June 2014, averaged 62 minutes, were audio-taped and transcribed, and were member-checked by the interviewees. Preliminary analyses, using a structured template, were conducted by evaluation team members using interview notes, audio-recordings, and transcripts. After identifying four primary domains: 1) integration of SM into the budget development process; 2) implementation of directive elements; 3) engagement of leadership and staff; and 4) use of data, we created an implementation score for each site using the following rating scale for each domain: 0 = absent, 1 = limited, 2 = adequate, 3 = outstanding. Scores ranged from 3.5 to 12, with 12 being the highest possible score. These scores were used to select three exemplar sites with low, medium and high implementation for more detailed case study analysis.

Results:
There was wide variation across all domains. Generally the high implementation site had leadership understanding and buy-in of SM, confidence in and ability to work with data, and integration of SM results into the budgeting process. The low implementation site reported poor leadership engagement and little understanding of data. Their low confidence in the process was a barrier to the use of SM recommendations in the budgeting process.

Implications:
Implementing SM in facilities with complex and changing staffing needs requires substantial commitment at all organizational levels. Specifically, learning to interpret and rely on data requires a considerable shift in thinking for many facilities that have traditionally relied on historical levels to budget for staffing.

Impacts:
Implementation of a sophisticated SM approach that takes into account the dynamic character of nursing units and patient need requires organizational changes including learning to interpret and rely on detailed unit-level data. To successfully meet the challenges inherent in such a change requires dedicated and on-going training.