Last updated: January 30, 2012
Select from the following questions
Denotes New or Updated Posting
Magnet Appraisal Process
What is the timeline for document submission after application?
In the section on "Notification of Events", why do organizations need to report sentinel events to the Magnet Program Office?
What advice can you give me about choosing a benchmarking database?
The 2008 Magnet Manual says that beginning in 2010 we need to submit unit-level data on all indicators listed.
We won't be able to have the data by then.
Education Requirements
What are the Educational Eligibility Criteria (at time of Application) for Chief Nursing Officer, Nurse Managers,
and Nurse Leaders?
If a nurse manager has a master's degree in nursing but not a baccalaureate in nursing, will that meet the requirements
that are outlined on p. 6 in the manual?
When collecting information about educational level of RNs, where do I count someone who has a bachelor of arts in nursing?
What is the New Source of Evidence that was Announced at National Magnet Conference?®
Electronic Documents
What are the requirements for electronic submission?
Certification
What certifications can be submitted on the Demographic Information Form (DIF) and represented in SE4EO to meet goals
for improvement in professional certification?
Demographic Information Form (DIF)
Should information on the Demographic Information Form (DIF) correspond to the 24 months prior to submission of
documentation that we use for our document?
Sources of Evidence
What is the best way to respond to SE3EO and SE4EO regarding goals for formal education and professional certification?
What is considered an innovation?
Submitting Documentation for Organizational Overview and EP3EO, EP32EO and EP35EO
Do outcomes have to be quantitative?
Can you explain more about the requirement to submit data that outperforms the mean of the national database used?
Are the outcomes weighted more in re-designation than in the original application?
Nurse Satisfaction
What is the best way to display nurse satisfaction data?
How often do we need to do the RN satisfaction survey?
In the organizational overview, does nurse (RN) satisfaction data need to be provided at the unit level?
During the off years, we do a house-wide employee engagement survey for the entire health system, from which we can
isolate results specific to the RN. Would this be acceptable?
Patient Satisfaction
What is the best way to display patient satisfaction data?
Nurse Sensitive Clinical Indicators
How should I present my nurse-sensitive indicator data?
Can you give some guidance about collecting data for Nurse Sensitive Indicators?
Is it required that we collect and benchmark falls and pressure ulcers in all areas?
We currently collect BSI and VAP data in two areas only. We do not benchmark these. Is it a problem that we aren't
benchmarking them?
In areas where VAP isn't appropriate to collect, is the assumption that we should be collecting and benchmarking other
data such as BSI, UTI, etc.?
For restraint use, what specific data is being requested? In-house restraints in use, or injuries related to restraints?
Outcomes – Other Than EP3EO, EP32EO, & EP35EO
How should I present my content and data for outcome sources other than EP3EO, EP32EO, and EP35EO?
Systems
We have 20 hospitals in one state. Would we qualify as large enough to be a comparison benchmark against ourselves?
If applying as a system, how is the data for Nurse Satisfaction, Patient Satisfaction, and the Nurse Sensitive
Indicator data presented?
New Knowledge, Innovation, and Improvements
How do I present the completed nursing research study in NK4EO?
Magnet Appraisal Process
What is the timeline for document submission after application?
Submission Dates
- New applicants may submit your online application on any day of the year AND the online application, application fee, and supporting documents (e.g., CNO Vitae, organizational chart, nationally benchmarked nurse satisfaction survey tool) must be received by the Magnet program office no later than 3 months prior to the month intended for written documentation submission.
- You may choose to submit your written documentation on the 1st business day of any of these months: February, April, June, August or October. A change in the documentation submission date will incur an extension fee. Note: Currently recognized Magnets will submit their written documentation on the first day of February, April, June, August or October, whichever is closest to the month of the organization's most recent designation.
Example:
If you wish to submit written documentation April 1, 2012, the application, fee, and supporting documents must be received by the Magnet Program Office no later than midnight January 1, 2012.
Magnet organizations submit their re-designation application with supporting documents one year prior to their document submission date. return to top
In the section on "Notification of Events", why do organizations need to report sentinel events to the Magnet Program Office?
An "adverse event" describes any harm (i.e., undesirable clinical outcome) to a patient as a result of medical care. The term "sentinel event" denotes a serious occurrence that signals the need for immediate investigation and response. Research, policies, and action taken to reduce adverse or sentinel events often focus on mistakes and systemic problems with care.
The Centers for Medicare & Medicaid Services (CMS) indicates that reducing the incidence of adverse events in hospitals is a critical component of efforts to ensure patient safety and to provide quality health care.
Various federal and state government agencies and other entities are responsible for addressing adverse events in hospitals. Additionally, hospitals must track and analyze adverse events as a condition of participation in the Medicare and Medicaid programs. Reporting events and suspected causes can help hospitals improve practices to prevent adverse events and ensure accountability for poor care. Hospitals also use reported information to inform affected patients and families, which is thought to boost public trust, and to improve clinical decision- making compliance in treatment.
The Magnet Recognition Program ® goal is to provide patients with a benchmark to measure the quality of care that they can expect to receive by recognizing quality patient care, nursing excellence, and innovations in healthcare services. Therefore, the Magnet program must be cognizant of the current healthcare industry trends—emphasizing quality of care, lower error rates, and non-payment for many adverse and sentinel events. Magnet® designation is an indication to customers not only of a quality nursing program within a healthcare organization, but also a signal that they can expect quality care because of recognized nursing excellence within a designated facility. For those reasons, the Commission on Magnet should track and trend the situations of adverse or sentinel events of organizations that hold the Magnet designation credential.
The reports should remove any identifiable patient health information and names of healthcare professionals involved.
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What advice can you give me about choosing a benchmarking database?
There is no Magnet-required process for approving databases or benchmarking choices. Organizations have the latitude to choose the tools that are most beneficial to them. The guidance is to choose the highest quality tool that is statistically significant, at the broadest level nationally available, with the largest cohort to get the greatest comparative value. In addition, review of the requirements in the Organizational Overview will provide applicants with the data elements that they need to make sure they are collecting, and also requires that some data be displayed at the unit level. return to top
The 2008 Magnet Manual says that beginning in 2010 we need to submit unit-level data on all indicators listed. We won't be able to have the data by then.
The Magnet program is moving the requirement to 2012 because of the lag in reporting benchmarking data. This should give organizations time to catch up. The requirement will be to submit data on all indicators, so you should be collecting now in order to have two years' worth of data to submit by 2012.
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Educational Requirements
What are the Educational Eligibility Criteria (at time of Application) for Chief Nursing Officer, Nurse Managers, and Nurse Leaders?
Chief Nursing Officer
Effective 2003 - The CNO must have at a minimum, a master's degree at the time of application. If the master's degree is not in nursing then either a baccalaureate degree or doctoral degree must be in nursing. The requirement must be maintained throughout the application phase, review phase, and designation as a Magnet organization. Appointees as interim CNOs must also comply with this requirement.
Nurse Managers
A Registered Nurse with 24 hour/7day accountability for the overall supervision of all Registered Nurses and other healthcare providers in an inpatient or outpatient area. The Nurse Manager is typically responsible for recruitment and retention, performance review, and professional development; involved in the budget formulation and quality outcomes; and helps to plan for, organize and lead the delivery of nursing care for a designated patient care area.
Effective 1/1/2011 (at time of application) – 75% Nurse Managers must have a degree in nursing
(baccalaureate or graduate degree)
Effective 1/1/2013 (at time of application) – 100% Nurse Managers must have a degree in nursing
(baccalaureate or graduate degree)
Nurse Leaders
Those nurse leaders with line authority over multiple units that have RNs working clinically and those nurse leaders who are positioned on the organizational chart between the nurse manager and the CNO.
Effective 1/1/2013 (at time of application) – 100% of nurse leaders must have a degree in nursing
(baccalaureate or graduate degree)
Validation
CNO will attest to this eligibility requirement on application.
When written documentation is submitted the organization will include a table* that identifies each nurse manager and
nurse leader and their highest nursing degree.
Final verification will occur during the site visit.
*Table is located on the website under "Table and Templates "
Nurse Manager and Nurse Leader Eligibility Documentation [xls: 17KB] updated 3/31/2011
Use this tool to document the highest nursing education, baccalaureate or graduate degree, of nurse managers and leaders, to demonstrate compliance with eligibility criteria. Provided at time of written documentation submission. return to top
If a nurse manager has a master's degree in nursing but not a baccalaureate in nursing, will that meet the requirements that are outlined on p. 6 in the manual?
The requirement is for at least a bachelor's degree in nursing. The Commission on Magnet (COM) believes that it is essential that nurse managers know the theory base for the profession. This theory base is required in curricula for bachelor's, master's, and doctoral degrees in nursing.
The criterion states that effective January 1, 2011, 75% of nurse managers must have at least a baccalaureate in nursing. A higher degree in nursing (a master's or doctorate in nursing), will meet the requirement even if the baccalaureate degree is not in nursing. return to top
When collecting information about educational level of RNs, where do I count someone who has a bachelor of arts in nursing?
The category will read baccalaureate in nursing. If the RN holds a bachelor of science in nursing or a bachelor of arts in nursing, it should be counted in the baccalaureate category. return to top
What is the New Source of Evidence that was Announced at National Magnet Conference®?
Pat Reid Ponte, chair of the commission on Magnet, announced at the 2011 National Magnet Conference® that a new source of evidence (SOE) will be added to the Magnet Application in 2013. The new SOE supports the Institute of Medicine’s recommendation to increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Dr. Reid Ponte told those in attendance that the Commission on Magnet reviewed the IOM report and identified areas where the Magnet Recognition Program® can be of support in actualizing the recommendations.
The source of evidence reads: "Provide an action plan and set a target, which demonstrates evidence of progress toward having 80% of direct care nurses obtain a baccalaureate degree in nursing or higher by 2020."
The source of evidence will be effective June 1, 2013.
Organizations submitting documentation anytime on or after June 1, 2013, regardless of the application date, will be expected to address the SOE. The SOE will not be scored during the period of June 1, 2013 – June 1, 2015. The Commission on Magnet will review the results of the source of evidence, making a decision on the scoring prior to June 1, 2015. return to top
Electronic Documents
What are the requirements for electronic submission?
The Magnet Recognition Program Office (MPO) must be notified of the organization's intent to submit documentation
in electronic format. It is necessary to inform the MPO of the system requirements to run the electronic documentation
no later than two months in advance of submission.
The electronic documentation submission may be forwarded on a CD-ROM, flash drive, Web-based format or via an FTP site.
The submission must be clearly labeled with the name of the organization.
The Organizational Overview volume may be submitted on the electronic medium in folder/file format.
A hard copy of the entire documents should be prepared in the event the electronic submission fails to function.
The Demographic Information Form should be sent:
As an attachment via email to the Magnet Analyst
As hard copy included with documents
The links to attachments and/or to other documents (either Organization Overview or reference documents) must,
when closed, return the reader back to the location of the link in the text where the reader left the narrative.
The links to attachments and/or to other documents (either Organization Overview or reference documents) must,
when closed, return the reader back to the location of the link in the text where the reader left the narrative.
Each page of the Organization Overview, the component narratives, and reference documents must be paginated.
Include instructions on how to navigate as a file in the electronic submission medium (thumb drive/CD-ROM, etc).
If you have placed bookmarks in the document, provide an explanation regarding how to use them.
The Table of Contents needs to be organized in the same order as in the Manual: OO, TL, SE, EP, NK. Incorporate the EOs
with related sources of evidence and references/appendices.
For each component section there needs to be a separate, detailed, Table of Contents detailing the page numbers for
each source of evidence.
There must be a consistent method of handling reference material: either as a link out of source word document or within
the source word document.
Glossary terms may either be built into the source word document or use a "go to" Glossary link; don't mix the approaches.
Graphs must be loaded into the source word document.
All graphs, tables, and diagrams must be labeled by source, i.e. SE4EO in the source documents or when navigating
through multiple links.
Avoid characters like # which, when placed before the link to documents, stops the ability to open the linked document.
Electronic documents may be rendered in "read-only" format; however, the format must allow for the selection of text
(to copy and paste if necessary).
When submitted, each appraisal team member and the MPO will receive a CD-ROM/thumb drive or Web log-In/password
on the designated documentation submission date.
If submitting a Web-based application, a copy of the documentation must be submitted to the MPO via CD-ROM, thumb drive
or hard copy.
The Magnet component volumes and related references (other than the Organizational Overview items) must, when
printed in a hard copy version, meet the measurement limit of 15 inches.
The envelope containing the labeled electronic medium (i.e. CD-ROM, thumb drive, etc.) must include a printed version of
the Demographic Information Form (DIF), and glossary (containing defined acronyms and abbreviations used in the
documentation) on a color of paper that is easily identified. return to top
Certification
What certifications can be submitted on the Demographic Information Form (DIF) and represented in SE4EO to meet goals for improvement in professional certification??
The following is a list of "core" features that the Magnet Recognition Program® uses to assess whether a specific credential is one that applicants may include on the Demographic Information Form (DIF) and use to represent goals for improvement in professional certification for SE4EO in the 2008 Magnet Manual.
The credential is a professional certification* if:
The examination is nationally available.
The examination is based on periodic job analysis (role delineation studies and content panel experts)
A recertification interval is defined.
The examination tests a professional body of knowledge (i.e., not technical-ACLS, BCLS, ATLS etc.)
No specific classes are required to be eligible for the examination.
*Although, not a requirement for inclusion, the Magnet Recognition Program® does note whether the certification is accredited by the National Commission for Certifying Agencies (NCCA) and/or the American Board of Nursing Specialties (ABNS). .
Check the Magnet Recognition Program page for information about the different levels of certification. return to top
Demographic Information Form (DIF)
Should information on the Demographic Information Form (DIF) correspond to the 24 months prior to submission of documentation that we use for our document?
As much as possible, you should work to line up the data timelines. However, there is often a time lag in reports being disseminated, and there are also constraints on data collection timelines that the organization cannot control (for example, data submission is required on a certain date). Some organizations use different data collection processes and have different timetables for reports. The data submitted should be from the time period closest to document submission that is consistent with your organization's data systems. return to top
Sources of Evidence
What is the best way to respond to SE3EO and SE4EO regarding goals for formal education and professional certification?
Magnet Expectations for SE3EO
The following information is required in the written documents:
A stated goal or goals (a number or percentage) for improvement of formal education for nurses:
This can be for any group of nurses in the organization that you choose.
The goal can be for the entire 2-year period prior to document submission or for each year of the 2-year reporting
period each goal that is stated must be acknowledged in the documents as met or exceeded.
If you provide (3) different goals, all must be identified as met or exceeded
For each goal presented, you must provide 2 years of graphed data to demonstrate that the goal/goals are met or exceeded.
Examples
A goal would be an identified number (such as 5) of all of your critical care nurses to complete a BSN program every year for the 2 year reporting period. For a 2012 document submission, you should show data for the years of 2010 and 2011, with a starting point of the number of critical care nurses who have a BSN degree in 2009, such as:
Goal: increase of (5) critical care nurses per year, for 2010 and 2011, to complete a BSN program:
| 2009 (starting point) |
4 critical care nurses with a BSN degree |
| 2010 (first year increase) |
9 critical care nurses completed |
| 2011 (second year increase) |
15 critical care nurses completed |
Or the goal may be a 5% increase of critical care nurses who have completed a BSN program for the entire 2-year reporting period. For a 2012 document submission, you would show data starting with the percentage of critical care nurses who have a BSN degree in 2009 (provide numerator/denominator numbers of the number of critical care nurses with a degree over the total number of critical care nurses) and the same count at the end of the 2-year period in 2011, such as:
Goal: increase of 5% of critical care nurses from 2009 (Jan – Dec) to 2011 (Jan-Dec) to complete a BSN program (2010-2011 being the 2-year reporting period):
| 2009 (starting point) |
4 /30 critical care nurses with BSN degree (13%) |
| 2011 |
9/32 critical care nurses completed (28%) |
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What is considered an innovation?
Innovations:
Are a novel set of behaviors, work and ways of working
Are a group of activities that are generated and directed toward improving:
Health outcomes
Cost effectiveness
Users' experience
Are implemented by planned and coordinated actions
Are focused toward positive change, with the intent to make someone or something better
Cause changes in thinking, products, processes, or organizations
Those who are directly responsible for application of an innovation are often called pioneers. return to top
Submitting Documentation for Organizational Overview and EP3EO, EP32EO and EP35EO
Do outcomes have to be quantitative?
Outcomes are results, impacts or consequences of actions. For any of the outcome Sources of Evidence there must be documentation that describes a beginning and end, cause and effect, of what is being presented. When responding to the outcome sources include the following information in your response:
Describe the purpose and the background
Describe how the work was done
Discuss who was involved and what units participated
Describe the measurement used to evaluate the outcomes and the impact
(show results and significance of results)
Present pre-intervention data and post-intervention data (cause and effect) and the time period involved.
In addition to responding to the bullets described above, use graphs and charts to illustrate outcomes. return to top
Can you explain more about the requirement to submit data that outperforms the mean of the national database used?
The 2008 Magnet Manual includes Sources of Evidence that require the submission of outcome measurement data. These data are included as evidence for the Empirical Outcome Sources of Evidence to demonstrate that your organization is in the top half of nationally benchmarked organizations.
Applicant and Magnet-designated organizations are expected to contribute their own data (patient and nurse satisfaction, clinical nurse-sensitive indicators) to a national database that compares the organization's data against cohort groups at the national level and to demonstrate that the majority of the units outperform the national benchmark for majority of the time that data are collected.
It is anticipated that over time, this threshold will be increased as Magnet-designated organizations continue to improve performance.
So, for example, for unit level data presentation, if an organization had nine patient care units, at least five of them have to outperform the mid-point more than half the time. return to top
Are the outcomes weighted more in re-designation than in the original application?
The requirements for redesignation require that all of the outcomes Sources of Evidence delineated in the manual as EO (Empirical Outcome) are addressed. Since there are fewer overall Sources of Evidence to address in re-designation (60), and all of the outcome sources (19) need to be addressed, the "weight" of the outcomes sources will be emphasized in redesignation. return to top
Nurse Satisfaction
What is the best way to display nurse satisfaction data?
For OO12 Organizational Overview requirement
Provide the two (2) most recent unit-based, nationally benchmarked nurse satisfaction or engagement surveys. The preference is that the same tool be used for both surveys. Provide data for each unit. If the measurement tool has subscales, data should be displayed at the sub-scale level. If available, include the levels of statistical significance as compared to the benchmark.
Include a graphic display and a table of the data that clearly identify:
The database to which the data was contributed
The mean or median of the national benchmark (select one cohort such as hospitals, bed size, Magnet hospitals, etc.)
Labels for each axis
For EP3EO requirement
Submit data for the most recent annual or bi-annual nurse satisfaction or engagement survey and include the mean or median of the national database used. This data can be displayed at the single unit level (such as ICU, CCU, SICU); or by clinical groups of multiple like-units (such as critical care, medical, surgical, medical-surgical, rehabilitation, and ambulatory); or at the organizational level. Data must be statistically valid and provided by the vendor. Keep in mind that the majority of the data must outperform the mean or median the majority of the time.
The narrative must include:
Participation rates
Analysis, and evaluation of the data
The database to which the data was contributed
Include a graphic display and a table of the data that clearly identify:
All data from the most recent survey cycle within the last two (2) years.
The benchmark mean or median for the selected cohort (select one cohort such as hospitals, bed size, Magnet hospitals, etc.)
Labels for each axis
NOTE: Do not include internally benchmarked data. return to top
How often do we need to do the RN satisfaction survey?
The nursing satisfaction surveys do not need to be done annually. Whether those are annual or every two years is up to your organization. return to top
In the organizational overview, does nurse (RN) satisfaction data need to be provided at the unit level?
Yes, you need to submit unit-based nationally benchmarked data. return to top
During the off years, we do a house-wide employee engagement survey for the entire health system, from which we can isolate results specific to the RN. Would this be acceptable?
One thing to consider is the comparability of the indicator set. You must have two data points from the same survey tool to compare results. You must assure that it is benchmarked as part of a nationally representative sample. In addition, data needs to be available for RNs by unit, even in the house-wide survey. As long as those conditions are met, you may use whatever survey instrument you wish.
If special circumstances prevent your organization from comparing two data points from the same survey tool, a detailed explanation must be included in the written documents. Every effort needs to be made to compare results between similar concepts for nurse satisfaction over time.
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Patient Satisfaction
What is the best way to display patient satisfaction data?
If uncertain, please contact the Magnet Program Office (MPO) to evaluate whether the vendor administering the patient satisfaction survey in your organization provides unit level, nurse specific data that is benchmarked at the national level. The collection of the data and the comparison groups vary by vendor, so it is best to check with the MPO before planning to submit written documentation
For OO26 Organizational Overview Requirement
Provide unit-based, nationally benchmarked data for patient satisfaction with nursing for the most recent two-year period. Provide quarterly data for every unit for four of the measures listed below. If available, include the levels of statistical significance as compared to the benchmark.
Pain
Education
Courtesy and respect from nurses
Careful listening by nurses
Response time
Include a graphic display and a table of the data that clearly identify:
The database to which the data was contributed
The mean, median, or other benchmark statistic of the national database used (select one cohort such as hospitals, bed size,
Magnet hospitals, etc.)
Labels for each axis
For EP35EO Requirement
Submit data for the most recent eight quarters of data for four measures related to patient satisfaction with nursing (listed below) and include the mean or median of the national database used. This data can be displayed at the single unit level (such as ICU, CCU, SICU); or by clinical groups of multiple like-units (such as critical care, medical, surgical, medical-surgical, rehabilitation, and ambulatory); or at the organizational level. Data must be statistically valid and provided by the vendor. Keep in mind that the majority of the data must outperform the mean or median the majority of the time.
Pain
Education
Courtesy and respect from nurses
Careful listening by nurses
Response time
The narrative must include:
Analysis, and evaluation of the data and resultant action plans
The database to which the data was contributed
Include a graphic display and a table of the data that clearly identify:
All data from the most recent eight quarters
The benchmark mean, median, or other benchmark statistic for the database used for each quarter, for the selected cohort
(select one cohort such as hospitals, bed size, Magnet hospitals, etc.)
Labels for each axis
NOTE: Do not include internally benchmarked data. return to top
Nurse Sensitive Clinical Indicators
How should I present my nurse-sensitive indicator data?
Can you give some guidance about collecting data for nurse-sensitive Indicators?
The intent is to collect data that is applicable and value-added for the particular unit and organization. Organizations must contribute their own data (patient and nurse satisfaction, clinical nurse-sensitive indicators) to a national database that compares the organization's data against cohort groups at the national level.
When a national database is available, it must be used. If a national database is not available for unique clinical areas/subjects, an organization can choose another appropriate way to benchmark. An organization can choose another benchmarking measure or database as long as the organization can justify the reason for choosing that measure or database. Benchmarking should be done at the highest level possible (national, state, specialty-specific) to have meaning and value. Appraisers will ask: Why are you using it? What did you use to determine measure? What else did you look at?
Example: Many specialty pediatric hospitals across the country formed a cohort and benchmarked against each other. retun to top
Is it required that we collect and benchmark falls and pressure ulcers in all areas?
It is required to collect falls and pressure ulcers on the units where this is an applicable data indicator, plus two other indicators from the list provided on page 21or 40 of the 2008 Magnet Manual. If your unit does not have falls or pressure ulcers as applicable indicator, then you only need to collect two of the indicators on the list. As a result, some units may be collecting two, three or four indicators to meet the intent of this requirement. At a minimum, each unit must collect at least two indicators, but no more than four are required. return to top
We currently collect BSI and VAP data in two areas only. We do not benchmark these. Is it a problem that we aren't benchmarking them?
BSI and VAP data can and must be benchmarked to address Magnet Sources of Evidence. We suggest you participate in a comparative database (such as those that are publicly available on the Center for Disease Control's National Healthcare Safety Network data set) to benchmark these indicators. If a national database is available, it should be used. But an organization can choose another appropriate way to benchmark for clinical areas/subjects not covered by a national database. An organization can choose another benchmarking measure as long as the facility can justify the reason for choosing that measure or database. Benchmarking should be done at the highest level possible to have meaning and value. Appraisers will ask: Why are you using it? What did you use to determine the measure? What else did you look at? return to top
In areas where VAP isn't appropriate to collect, is the assumption that we should be collecting and benchmarking other data such as BSI, UTI, etc.?
It is required to collect falls and pressure ulcer data on the units where applicable, plus two other indicators from the list provided on page 21 or 40 of the 2008 Magnet Manual. If your unit does not have falls or pressure ulcers as an applicable indicator, then you only need to collect two of the indicators on the list. return to top
For restraint use, what specific data is being requested? In-house restraints in use, or injuries related to restraints?
It depends on the database being used and how restraints are defined. Submit the restraint indicators that have benchmark data. return to top
For OO23 Organizational Overview Requirement
Provide unit-based, nationally benchmarked nurse-sensitive clinical indicator data related to patient outcomes for the most recent two-year period. Provide quarterly data for every unit for which all patient falls and all nosocomial pressure ulcer incidence and/or prevalence are applicable. If available, include the levels of statistical significance as compared to the benchmark.
Additionally, for each unit, display data for two (2) other applicable nurse-sensitive clinical indicators selected from the list below:
Blood stream infections
Urinary tract infections
Ventilator-associated pneumonia
Restraint use
Pediatric IV infiltrations
Other specialty-specific nationally benchmarked indicators
Note: By 2012, organizations must provide unit-level data on all applicable indicators.
Include a graphic display and a table of the data that clearly identify:
The database to which the data was contributed
The mean or median of the national benchmark (select one cohort such as hospitals, bed size, Magnet hospitals, etc.)
Labels for each axis
Whether a data point is 'no data submitted' or 'zero' return to top
Exceptions:
Obstetric areas present a unique situation related to nursing sensitive indicators. Hospital-acquired pressure ulcers and
pediatric IV infiltrates do not apply and OB patients rarely have blood stream infections, urinary tract infections,
ventilator- associated pneumonia, or restraints. It would be appropriate for them to choose two of the "other specialty
specific indicators."
In ambulatory care areas, hospital-acquired pressure ulcers and pediatric IV infiltrates may not apply, nor do blood stream
infections, urinary tract infections, ventilator- associated pneumonia, or restraints, in most situations. It would be appropriate
for them to choose two of the "other specialty specific indicators."
In any areas where the number of RNs is small, with only one or two RNs, one indicator may be appropriate and reasonable,
as organizations attempt to balance productivity with performance improvement. Just be sure to explain why an area does not
have two indicators, as the expectation is that nurses are critically examining their practice for opportunities for improvement
wherever they practice.
For EP32EO Requirement
Submit data for the most recent eight quarters of data for four nurse-sensitive clinical indicators and include the mean or median of the national database used. This data can be displayed at the single unit level (such as ICU, CCU, SICU); or by clinical groups of multiple like-units (such as critical care, medical, surgical, medical-surgical, rehabilitation, and ambulatory); or at the organizational level. Data must be statistically valid and provided by the vendor. Keep in mind that the majority of the data must outperform the mean or median the majority of the time.
Two (2) of the indicators must be all patient falls and all nosocomial pressure ulcer incidence and/or prevalence if applicable.
Two (2) other indicators must be selected from the list below:
Blood stream infections
Urinary tract infections
Ventilator-associated pneumonia
Restraint use
Pediatric IV infiltrations
Other specialty-specific nationally benchmarked indicators
The narrative must include:
Analysis, and evaluation of the data
The database to which the data was contributed
Include a graphic display and a table of the data that clearly identify:
All data from the most recent eight quarters.
The benchmark mean or median for each quarter, for the selected cohort (select one cohort such as hospitals, bed size,
Magnet hospitals, etc.)
Labels for each axis
Whether a data point is 'no data submitted' or 'zero'
NOTE: Do not include internally benchmarked data return to top
Outcomes – Other Than EP3EO, EP32EO, & EP35EO
How should I present my content and data for outcome sources other than EP3EO, EP32EO, and EP35EO?
Describe and demonstrate (provide evidence):
The change, improvement, or effectiveness
Measurement
Dates – when the work was done
• Quarters, months, yearly, fiscal year
Pre intervention data
Post intervention data
Make the connection between work done and outcomes achieved
Systems
We have 20 hospitals in one state. Would we qualify as large enough to be a comparison benchmark against ourselves?
The requirement is to benchmark against a nationally representative sample. The larger the comparative cohort, the more valuable the data set on which to base your improvement efforts. While it is always helpful to compare yourself to other hospitals in your state, 20 hospitals in one state would not qualify as a nationally representative sample for comparison benchmark for Magnet. If you have questions, or are unsure, it is always a good idea to call the Magnet Program Office and talk to your analyst. return to top
If applying as a system, how is the data for Nurse Satisfaction, Patient Satisfaction, and the Nurse Sensitive Indicator data presented?
System Applications: For those organizations submitting as a system a separate Demographic Information Form (DIF), Research Table, and Nurse Manager Education Eligibility Table must be completed for each component organization of the system and submitted electronically via email to the Magnet Program Office at time of documentation submission.
System Written Documentation - In addition to the above required documents the data for 0012 and EP3EO (Nurse Satisfaction), 0023 andEP32EO (Nurse Sensitive Clinical Indicators), and 0026 and EP35EO (Patient Satisfaction) must be presented separately for each organization submitted in the system application. Separate tables and graphs must be presented for each organization. For NK4EO one completed research study must be presented for each organization or there must be clear representation by each organization if a combined study is presented. The outcome data must show an impact for each organization. return to top
New Knowledge, Innovation, and Improvements
How do I present the completed nursing research study in NK4EO?
The outline below provides the format recommended to address the SOE.
Purpose and Background :
research question or hypothesis
brief summary of review of literature
Method:
type of study (quantitative, qualitative, or combination)
specific methodology
study population
how data was collected
Participants:
nurses at the organization who are the PI or involved in the conduct of the study
Outcome:
Outcome and Impact on the organization - show results of data analysis (quantitative) or findings (qualitative) and significance of the results return to top