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Magnet Recognition Program® FAQ: Data and Expected Outcomes

Last updated: June 7, 2013

Select from the following questions

Denotes New or Updated Posting

Magnet Appraisal Process

Education Requirements

Electronic Documents

Certification

Demographic Data Collection Tool™ (DDCT™)

Sources of Evidence

Submitting Documentation for Organizational Overview and EP3EO, EP32EO and EP35EO

Nurse Satisfaction

Patient Satisfaction

Nurse Sensitive Clinical Indicators

Outcomes – Other Than EP3EO, EP32EO, & EP35EO

Systems

New Knowledge, Innovation, and Improvements


Magnet Appraisal Process

Preparing documentation for submission
For TL, SE, EP, and NK Sources of Evidence, to meet Magnet Expectations, the documentation for each SOE must have:

  • Description (narrative page 16 manual) that concisely conveys how the elements of the Sources of Evidence are present and operationalized within the organization. (Examples and testimonial statements are considered part of the narrative and not evidence)
  • Demonstration (evidence/exhibits page 17 manual) provides verification that what is stated in the narrative actually exists in the organization. Evidence is something in writing from your organization that shows use of structures and processes or how something is done in the organization.
    • Examples of acceptable evidence: copies of policies and procedures, meeting minutes, various types of correspondence, data, rosters, screenshots.
    • DOES NOT include examples and testimonial statements.

For EO Sources of Evidence, to meet Magnet expectations, the (4) required criteria on page 34 (New Applicant) and page 52 (Re-designation) of the manual must be included:

Purpose/Background: statement of a problem or a need and the goal or intent to improve a situation relevant to the organization

  • Methods: "work done by nurses"; an intervention or implementation of process or program.
    • Must identify: time period of the intervention or implementation.
  • Participants: include nurses involved in the intervention or program
  • Outcomes and Impact (show results and significance of the results):: must include data points that show measurable change, improvement, or a result of the work done by nurses which was described in the Methods section.
    • Must include:
      • Pre-implementation data and time period/date: metric that reflects the problem or need which was described in the "Purpose" section
      • Post-implementation data and time period/date: re-measure of the pre-implementation data point after an intervention or program was implemented by nurses
  • Only provide the number of examples requested in the Source of Evidence statement, one or two.

Suggested Format for presenting SOE:

TL10EO: Describe and demonstrate changes in the work environment and patient care based on input from the direct-care nurses

Work environment example:

Purpose and Background: (Describe problem and goal). The pre and post data should be measures related to the problem and or goal.

Intervention: (1. Describe the work done to correct the problem stated in the purpose and background and; 2. Identify the timeframe (year/month or quarter) that the intervention occurred:

Participants:

Outcome: 1. Identify the pre-intervention data and the timeframe year/month or quarter and 2. Identify the post-intervention data and the timeframe year/month or quarter.
Patient Care example:

Purpose and Background: (Describe problem and goal)

Intervention: (1. Describe the work done to correct the problem stated in the purpose and background and; 2. Identify the timeframe (year/month or quarter) that the intervention occurred:

Participants:

Outcome: 1. Identify the pre-intervention data and the timeframe year/month or quarter and 2. Identify the post-intervention data and the timeframe year/month or quarter.

SE5: Describe and Demonstrate the structure(s) and process(es) used by nursing to develop and provide continuing education programs for nurses at all levels and settings. Include how the organization provides onsite internal electronic and classroom methods. Do not include orientation.

Structure: (Characteristics of the organization)

  • Develop continuing education programs – all levels:
  • Provide continuing education programs – all levels:

Process: (Actions; see description above)

  • Develop continuing education programs – all levels:
  • Provide continuing education programs – all levels:

Evidence: (see description above)

EP1 Describe and Demonstrate how nurses develop, apply, evaluate, adapt, and modify the Professional Practice Model.

How: (What is done by the nurses)
  • Develop:
  • Apply:
  • Evaluate:
  • Adapt:
  • Modify:

Evidence:

  • Develop:
  • Apply:
  • Evaluate:
  • Adapt:
  • Modify:

Timeline to comply with the requirement that information in the narrative, evidence and data provided must be within the two years prior to documentation submission

The two year reporting period which includes narratives, evidence and data, may end up to the date of submission but may not go back any earlier than two years and 6 months prior to the documentation submission date. See page 16, 2008 manual.

This does not apply to quarterly data for EP3EO, EP32EO, or EP35E0 where the database controls the quarters.

Examples of 2 year reporting periods for all 5 submission dates in 2013 are displayed below.

Documentation
submission year 2013
February 2013 April 2013 June 2013 August 2013 October 2013
Must provide documentation at least until this month: August 2012 October 2012 December 2012 February 2013 April 2013
Can go back only to: No earlier than August 2010 No earlier than October 2010 No earlier than December 2010 No earlier than February 2011 No earlier than April 2011

Specific Sources of Evidence:

  • TL4 and TL4EO
    • Focus for these Sources of Evidence is on CNO influence beyond nursing at the organizational level involving multiple departments/disciplines.
  • Revised and most current wording for TL10 (see Manual update section on the website):
    • Nurse leaders use input from direct care nurses to improve the work environment and patient care.
  • Revised and most current wording for SE2 and SE2EO:
    • professional nursing organizations
  • SE1:
    • must address structure/process, nurses from all settings/roles
    • nurse participation in decision-making groups at the organizational level (i.e. Pharmacy and Therapeutics, Infection Control, etc.), not within nursing
  • SE3EO and SE4EO:
    • Must identify goal/s for any group of nurses within the organization with open narrative to complement the information contained in the graph(s)
    • Must demonstrate that the goal or each goal, if more than one identified, has/have been met or exceeded – with 2 years of graphed data.
    • See FAQ for examples of how to present information
  • SE5EO: data must show effectiveness of an educational program for nurses (i.e. measurement of knowledge before and after the program)
  • EP29: workplace advocacy initiatives (i.e. nursing staff) – must address all four
    • Caregiver stress
    • Diversity
    • Rights
    • Confidentiality
  • EP20:
    • Address all levels of nurses, staff nurse up through and including CNO
    • Evidence must show completed tools/forms (no blank forms) for each level that demonstrate:
      1. self-performance appraisal, 2. peer review, and 3. annual goal-setting
  • NK2:
    • Provide a majority of meeting minutes (i.e. at least half/each year) and voting rosters from the 2-year reporting period to show consistent involvement of nurses.
    • Provide evidence that validates that a nurse votes on nursing related protocols
      OR
    • A letter, signed and dated by the Chair of the IRB that details specific dates of IRB meetings and lists the name(s) of the nurse(es) attending and voting on nursing related protocols is acceptable. Meeting minutes will be reviewed during the site visit to validate this information.
  • NK4EO: 2 parts:
    • Table of all nursing research activity from the 2 year period prior to document submission.
    • Description of one completed nursing research study from the 2-year period prior to document submission. See required format below:

      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

  • Page 34 and 52 display of data does not apply to SE3EO, SE4EO, EP3EO, EP32EO and EP35EO. Use table and graphs with supporting narrative.

NEW Organizational Overview Item - 80% of registered nurses obtaining a degree in nursing (baccalaureate or graduate degree) by 2020

Organizations submitting documentation anytime on or after June 1, 2013, regardless of the application date, will be expected to address the new education item in the Organizational Overview:

  • An action plan that includes a target of (and that demonstrates evidence of progress toward) 80% of registered nurses obtaining a degree in nursing (baccalaureate or graduate degree) by 2020. Include an assessment of the current status; an evaluation of methods and strategies to increase the educational level of the workforce; and an appraisal of established, realistic targets to meet the organization’s strategy to increase the number of registered nurses with a degree in nursing (baccalaureate or graduate degree).

Action plan will be included as the last item in Organizational Overview. 

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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 6 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 August 1, 2013, the application, fee, and supporting documents must be received by the Magnet Program Office no later than midnight February 1, 2013.

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. return to top

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


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.

  • 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.

  • 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®?

NEW Organizational Overview Item - 80% of registered nurses obtaining a degree in nursing (baccalaureate or graduate degree) by 2020

Organizations submitting documentation anytime on or after June 1, 2013, regardless of the application date, will be expected to address the new education item in the Organizational Overview:

  • An action plan that includes a target of (and that demonstrates evidence of progress toward) 80% of registered nurses obtaining a degree in nursing (baccalaureate or graduate degree) by 2020. Include an assessment of the current status; an evaluation of methods and strategies to increase the educational level of the workforce; and an appraisal of established, realistic targets to meet the organization’s strategy to increase the number of registered nurses with a degree in nursing (baccalaureate or graduate degree).

Action plan will be included as the last item in Organizational Overview.  return to top


Electronic Documents

What are the requirements for electronic submission?

  • Approximately two months prior to documentation submission, the organization must notify The Magnet Recognition Program Office (MPO) of the intent to submit documentation in electronic format prior to documentation submission. At this time, any system requirements should be provided to the MPO.
  • Electronic documentation may be submitted on a CD-ROM, flash/thumb drive, in web-based format or via a FTP site.
  • A hard copy of the entire documentation submission should be prepared, in case the electronic file malfunctions. (See Appendix E, page 93, 2008 Magnet Application Manual). The Component Section of the electronic documentation must not exceed 15 inches, when the documentation of this Section is printed
  • Size of the Components section of the electronic document may not exceed 4,500KB =4.4MB=15inches hard copy word print only. (exclusive of tables, graphs and schematics).

Web-Based or FTP site

  • An archival (back-up) version of the documentation must be submitted to the MPO via CD-ROM, thumb drive or hard copy on the scheduled documentation submission date. This version of the documentation is intended to be a 'free-standing' version of the documentation and not a 'shortcut' link to the web-based document. The files should be operable outside the web 'environment'.

CD-ROM or Thumb Drive

  • Clearly label with the name of the organization
  • Organize the Organization Overview as described in Appendix E on page 93 of the 2008 Magnet Application Manual
  • Organize the Components by folder and file format. Label folders and files clearly to indicate relevant SOEs

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.
  • All links must be tested prior to sending CD-ROM/thumb drive or Web based documentation to the appraisers and the Magnet Office.
  • It is advisable that the links be tested on one or more computers outside the organization to make sure the links will function with a variety of browser settings and operating systems.
  • Upon receipt, if links do not open for the appraisers or the Magnet office, the organization will be notified.
  • Once notified, the organization will have 5 business days to correct the links or submit a hard copy of the written documentation. If the organization is unable to correct the links or submit a hard copy within the 5 business days, the review will be stopped. Options will be discussed with the Magnet Program Office (MPO) staff.

Instructions to be provided with the electronic medium:

  • How to navigate through the files located on the electronic submission.
  • If you have placed bookmarks in the document, provide an explanation regarding how to use them.
  • Table of Contents needs to be organized in the same order as in the Manual, i.e., OO, TL, SE, EP, NK. Incorporate the EOs with related Sources of Evidence. Note references/appendices on the Table of Contents.
  • For each Component section there needs to be a separate, detailed, Table of Contents detailing the page numbers to locate each Source of Evidence.
  • There must be a consistent method of handling reference material, either as a link out of or within the narrative which addresses the Source of Evidence.
  • Glossary terms may either be built into the narrative or linked to the Glossary.
  • Graphs must be loaded into the document. Copy graphs from Excel into Word or create them in Word; do not embed a link to an Excel graph in the electronic document.
  • All graphs, tables, and diagrams must be labeled by Source of Evidence, i.e. SE4EO, in the electronic document documents.
  • Avoid characters like # which, when placed before the link to a document, 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).
  • NO VIDEOS
  • NO Laptops, tablets, or notebooks

On the designated DOCUMENTATION SUBMISSION DATE, each appraisal team member and the MPO must receive:

  • A labeled CD-ROM/thumb drive or Web log-In/password
  • Glossary of Terms (containing defined acronyms and abbreviations used in the documentation) on a color of paper that is easily identified

In addition to the items listed above, send the MPO:

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Certification

What certifications can be submitted in the Demographic Data Collection Tool™ (DDCT™) 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 in the Demographic Data Collection Tool™ (DDCT™) 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 Data Collection Tool™ (DDCT™)

Should information presented on the report submitted via the DDCT™ correspond to the 24 months prior to submission of documentation that we use for our document?
As much as possible, you should line up the data timelines. However, there is a time lag in reports being disseminated, and there are 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?

Nurse Satisfaction
OO12 & EP3EO Comparison
Organizational Overview Source of Evidence
• Two most recent surveys • Most recent survey
• National benchmark • Single unit, clinical group or organizational level data (provided by vendor)
• Unit level data
(use DDCT™ -Unit Names by Unit Type order)
• May use subscales "attitude areas", topics, indicators (such as RN-RN collegiality, Teamwork)
• If tool with subscales, display at subscale level • National benchmark for comparison
• Outperformance of the mean or median of benchmark
• Open narrative as analysis
 
© 2012 American Nurses Credentialing Center. All Rights Reserved.

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.)
    • Some databases provide more than one type of comparison. In those cases you are required to select the quarterly mean or median for the cohort of organizations that submitted data for that quarter rather than the rolling mean or median compiled over a longer period of time (e.g. one or two years).
    • 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, and rehabilitation); 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.)
    • Some databases provide more than one type of comparison. In those cases you are required to select the quarterly mean or median for the cohort of organizations that submitted data for that quarter rather than the rolling mean or median compiled over a longer period of time (e.g. one or two years).
    • 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 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-widesurvey. 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. return to top

Patient Satisfaction

What is the best way to display patient satisfaction data?

Patient Satisfaction
OO26 & EP35EO Comparison
Organizational Overview Source of Evidence
• Organized by unit • Organized by measure (pain, courtesy and respect, etc.)
• Provide data for all units • 4 required measures
• Unit level data for all units (use DDCT™-Unit Names by Unit Type order) • Unit level or organizational level
• Most recent 8 quarters • House-wide inpatient measures
• Show benchmark • Most recent 8 quarters
• Show outperformance of benchmark
© 2012 American Nurses Credentialing Center. All Rights Reserved.

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 nurse
    • 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.)
    • Some databases provide more than one type of comparison. In those cases you are required to select the quarterly mean or median for the cohort of organizations that submitted data for that quarter rather than the rolling mean or median compiled over a longer period of time (e.g. one or two years).
    • 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 nurse
    • 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.)
    • Some databases provide more than one type of comparison. In those cases you are required to select the quarterly mean or median for the cohort of organizations that submitted data for that quarter rather than the rolling mean or median compiled over a longer period of time (e.g. one or two years).
    • 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?

Clinical Indicators
OO23 & EP32EO Comparison
Organizational Overview Source of Evidence
• Organized by unit • Organized by clinical indicator
• Provide data for all units • 2 required measures
• Unit level data for all units (use DDCT™-Unit Names by Unit Type order) • Select 2 optional measures
• Most recent 8 quarters • Unit level or unit type (critical care) data
• Show benchmark • House-wide measures
• Most recent 8 quarters
• Show outperformance of benchmark
© 2012 American Nurses Credentialing Center. All Rights Reserved.

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 chooseanother 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.)
    • Some databases provide more than one type of comparison. In those cases you are required to select the quarterly mean or median for the cohort of organizations that submitted data for that quarter rather than the rolling mean or median compiled over a longer period of time (e.g. one or two years).
    • 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.)
    • Some databases provide more than one type of comparison. In those cases you are required to select the quarterly mean or median for the cohort of organizations that submitted data for that quarter rather than the rolling mean or median compiled over a longer period of time (e.g. one or two years).
    • 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?
Organizations submitting as a system will provide a separate demographic report via the Demographic Data Collection Tool™ (DDCT™), Research Table, and Nurse Manager Education Eligibility Table for each organization included in the system application. Each will be submitted with the documentation as well as a separate copy 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 the following must be presented separately for each organization included in the system application.

  • Separate tables and graphs must be presented for each organization.
    • NK4EO one completed research study must be presented for each organization or there must be data presented that clearly shows the impact of the nursing research study in each organization if a combined study is presented.
    • 0012 and EP3EO (Nurse Satisfaction), 0023 andEP32EO (Nurse Sensitive Clinical Indicators), and 0026 and EP35EO (Patient Satisfaction)
    • SE3EO (met goal for improvements in formal education) and SE4EO (met goal for improvement in professional certification). A goal may also be presented for the overall system, but the impact to each organization must be presented.

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