Session 12 - Performance Outcomes in HealthCare

NGU6400 – Block 01 Session 12: Performance Outcomes in HealthCare
Session 12
PERFORMANCE OUTCOMES IN HEALTHCARE
CONTENTS
Introduction
Define performance outcomes in health care
Define quality in nursing/healthcare
Historical factors and background of maintaining quality in healthcare
Effects of regulatory bodies and accreditation bodies in improving performance outcomes in
nursing / healthcare
Performance indicators in nursing
INTRODUCTION
Healthcare outcomes are the result of care in terms of the patient's health over time.
Advancing patient outcomes should be the ultimate goal for patient care. Use of these
performance outcomes in healthcare is an essential aspect for improving clinical care,
because it enhances the connections among the healthcare team and patients. Performance
outcomes are important in improving the patient experience of care as well as in improving
the health of populations in countries.
This session will discuss the importance of healthcare performance outcomes in measuring
the quality of available healthcare.
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Copyright©2019, The Open University of Sri Lanka
DEFINING PERFORMANCE OUTCOMES IN HEALTHCARE
The World Health Organization (WHO) defines an outcome measure as a “change in the
health of an individual, a group of people, or a population that is attributable to an
intervention or series of interventions.” The goals of measuring, reporting, and comparing
healthcare outcomes is to achieve the Quadruple aim of healthcare. Outcome measures
(mortality, readmission, patient experience, etc.) are defined as the quality and cost targets
that healthcare organizations are trying to improve.
A new strategy has been introduced in health care, namely, to achieve the best outcomes for
the lowest cost and through that to maximize the values for patients. In value‐ based care, the
only true measures of quality are the outcomes that matter to patients. When outcomes are
measured and reported, it helps the improvement and adoption of best practices among the
healthcare teams, further improving outcomes. Understanding outcomes is general to all the
setups in adding value and to redefine patient care.
MEASURING HEALTH CARE OUTCOMES
Measures are used to assess and compare the quality of health care organizations are
classified as either a structure, process, or outcome measure. This is known as the
Donabedian model, this classification system was named after the physician and researcher
who formulated it. Donabedian (2005), structure is defined as the places where medical
care takes place and the instrumentalities of each product and may include the features of
the system, the service provider or the patient. Process refers to the set of activities that
takes place, on the one hand, between professionals and, on the other, between
professionals and patients.
Structural Measures
Structural measures give consumers a sense on a health care provider on its capacity,
systems, and processes to provide high-quality care. For example
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 Whether the health care organization uses electronic medical records or medication
order entry and maintaining systems the number
 Proportion of board-certified physicians.
Process Measures
Process measures indicate what a provider does to maintain or improve health, either for
healthy people or for those diagnosed with an illness condition. These measures give an idea
on generally accepted recommendations for clinical practice. For example:
 The number of healthy people receiving preventive health services such as

immunizations, mammograms
 The percentage of people diagnosed with type 2 diabetes who had their blood sugar
levels tested and controlled.
Process measures can aware the consumers regarding medical care they should expect to
receive for a given condition or disease, and can contribute toward improving health
outcomes. The measures that are used for public reporting are process measures.
Outcome Measures
Outcome measures reflect the impact of the health care service on their intervention on the
health status of patients. For example,
 The number of patients who died after a surgery (surgical mortality rates)
 The number of complications or hospital-acquired infections after a surgical
procedure
Outcome measures are called to be representing the “gold standard” in measuring quality.
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However, there should be an updating process and a filtering method of these measures with
appropriate adjustments and amendments of them to minimize the reporting of misleading or
even inaccurate information about health care quality.
IMPORTANCE OF PERFORMANCE OUTCOMES IN NURSING
Performance outcomes stand to measure an organization’s performances or client/ patient

care outcomes. A newly arrived concept for healthcare is that to achieve the best outcomes
for the lowest cost and thus maximizing value and satisfaction for patients. Use of patient
reported outcomes is an essential aspect for improving clinical care, because it enhances the
connections among the healthcare team such as, doctors, nurses with patients. Designing and
implementing patient reported outcomes in clinical practices will lead to an understanding of
the effects of treatments on outcomes and quality of life (QOL) of our patients. This is one of
a key way to assess a patient's QOL. Furthermore, outcome measurement helps to cover the
full cycle of care, as well as follow‐ up care. Measuring and reporting outcomes is crucial for
learning and improving care over time. The healthcare team can look into their peers inside
and outside of the organization and observe their processes and can advance their selves
through constructive comparisons. . Furthermore, outcome improvement is a powerful
weapon for lowering costs and hence improving the value. Publication of the healthcare
outcomes helps the healthcare consumers to set clear expectations as well. That definitely
enhances the quality of health care delivery systems. These expectations indirectly play an
important role in establishing norms and facilitating improvements in healthcare outcomes.
Healthcare system around the world is changing like never before. One of the main reasons
for this change is the continuous expansion and advancement of the consumer’s/patient’s
need for quality.
QUALITY IN NURSING/HEALTHCARE
Measuring quality through performances is one way to determine the quality in health care.
The quality of health care can be measured or determined by how well a health care plan, a
setup or a health care provider such as a doctor, nurse or a para medical person keeps the
patients who are assigned to get their care in a healthy manner and treats them when they are
sick. When health care becomes high quality health care it means doing the right thing for the
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right person at right timing to get the best possible outcomes. The mostly used definition for
quality in healthcare is that “meeting or going beyond the patent’s expectations”. According
to the experts in the field quality is not a word, but a concept and based on the client’s
perspective. When it comes to nursing specially, good quality means providing patients an
appropriate care and facilitate services with good communication skills, shared decision
making opportunities and ethical/cultural considerations while maintaining a good
competency in skills and knowledge. This is strongly linked with informed consent as well.
Health care outcomes are a true measure of quality. For an example in a business, quality
should always be measured from the customer's perception and not the supplier's point of
view. This could be applied to the healthcare setup as well. Health care should not be any
different, and outcomes should be entered on the patient and not on the individual units or
specialty services providing the care. The public society these days is much updated and
search for information. So it does not take long for a healthcare provider or a providing
institute such as a hospital to become highlighted and neglected from the modern society. For
an example the general public can search and find out the best quality hospital out of a
several hospitals or the best consultant out of a few after referring to the statistics through
internet or other available printed materials. Likewise the patients/ clients always focus more
on the quality of the care before they choose a go to health care system.
The history of quality measures in Nursing
During the past recent years, health care quality measurement has become challengingly and
increasingly emphasized, as providers and hospital administrators respond to public and
government demands to minimize errors and improve patient care. The concept of patient
based care had been practising in the ancient society where it runs more than 150 years back
when Florence Nightingale treated and cared for solders. Ernest Amory Codman, who is a
surgeon from Harvard Medical School, is often believed and considered as the founder of
outcomes studies and evidence-based medicine formed several committees to check and
maintain hospital standards as well. After sometime, by 1952, the American College of
Physicians, the American Hospital Association, the American Medical Association, and the
Canadian Medical Association were joined with the ACS to form the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) to make sure that all the available
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healthcare facilitators including the persons and institutes develope their standards and
accreditation while providing better patient care.
After that in the late 1980s, under CAHO implemented a rigorous set of accreditation
standards, which reflected concepts presented by Avedis Donabedian in his 1966 article
addressing “Evaluating the Quality of Medical Care.” This was the very first imitative for the
quality based health care. This model evaluates healthcare under three categories which are,
 Structure, or the characteristics of health care delivery systems

 Process, or what and how care is provided
 Outcomes or the consequences of care.
The recent global program on enhancing and advancement of the quality in healthcare was
established in 2018 under the “Strategy for Quality Improvement in Health Care” as an
initiative of World Health Organization. It has been carried out under three aims over a
period of ten years. The three aims are,
 Better Care
 Healthy People/Healthy Communities
 Affordable Care
Maintaining the quality in Nursing and Healthcare
Maintaining a quality patient care and improving the care have become a top priority for all
health care providers with the overall objective of achieving a high degree of patient
satisfaction. When it comes to the nursing setup the fact that the patient is the most important
person in a medical care system must be recognized by all the nurses who work in the system.
This single factor makes a significant difference to the nursing care in any hospital. In
developing countries financial constraints often lead to compromised quality of care. This can
be corrected by introducing a system that could work on the cost effectiveness.
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Improvement of patient care is a dynamic process that should be an uppermost and a top
priority in the minds of nurses and all the other medical care personnel. Initially developing a
patient-sensitive system and improving it is most critical to achieve this objective. It is very
much important to pay attention to quality in every aspect of patient care. This could be done
in both medical and non-medical aspects.
Most of the health care providers have a better understanding on the medical aspects of
patient care. This mostly depends on the quality of expertise in the medical and technical
filed and the available equipment and quality assurance practices that are being practiced.
Following are the factors contribute to the improvement of patient care under medical aspect.
 Trained Personnel - Lack of adequate experts in the field and lack of adequate
knowledge and training facilities for the available personnel can be considered as
major problems. Recruiting of untrained or poorly trained people should be avoided.
The number of training programs must be increased, and the quality of existing
programs must be improved. A uniform basic curriculum for all the training
institutions/programs should help to maintain the standards of the program.
 Equipment - All the necessary equipment must be orderly in place and properly
maintained. This is a vital thing for a powerful performance of the medical system
and contributes for better results as well.
 Use of Proper Instruments - Good quality instruments should be available at lower
costs. With the development of proper inventory handling the costs can be lowered.
 Use of Appropriate Medications - Access to low cost medicines is an absolute
necessity for appropriate care. Even though the cost is low the quality should be high.
 Use of New Technologies - The continuous usage of new technologies that improves
the quality of care is important. Thus must be done while considering the cost-
efficiencies as well. For an example, when providing a total nursing care for a patient
a nurse should always look into new techniques rather than using the same old
method.
Being healthcare providers our experience shows that a system should first be developed to
attract the patients who can afford to pay for a high quality service. After that such a system
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should be extended to be available for non-paying patients as well. In nonmedical care things
that need to be addressed to improve patient care are as below,
 Access - Easy accessibility and availability of the hospital, the physician and the
health care team including nurses and other Para medical personnel should be assured
to all those who require health care.
 Waiting - In most of the developing countries, there’s a big waiting process due to
increased patient counts. Not Just in the government setup but also in the private
sector waiting at the channelling centers and such things are very common. Waiting
times for all services should be minimized. In most developing countries, the high
demand for healthcare services is the reason behind this problem. Nevertheless, it has
to be addressed effectively through continual review of patient responses and other
data and using this feedback to make the necessary changes in systems.
 Information - All the patients in all form of sectors have a right and an autonomy to
know the information and instruction about all procedures and treatment methods that
are being performed on them. Not just the patient his/her family members should also
be well informed and aware on everything that is going on related to the patient.
 Communication - Proper communication with the patient and the family about
possible things that could happen regarding the prognosis could minimize and can
avoid a lot of frustration and anxiety.
 Ancillary Services - Other services such as sanitary facilities, food, laundry and etc.
should be accessible both to patients and to attending families.
Activity
1. Recollect the memory of a patient you have cared for who experienced a
myocardial infarction. According to your experience and knowledge describe how did you as
a nurse and the healthcare team managed to provide a quality care for the patient.
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REGULATORY BODIES AND ACCREDITATION BODIES IN

WORLDWIDE IMPROVING PERFORMANCE OUTCOMES IN
HEALTHCARE
According to Lovern (2000) accreditation involves the certification of a program, service,

organization, institution or an agency by an authorized external body using process to assess
healthcare performance. This is mainly to establish standards in order to support continuous
improvement. Understanding the purpose of these different bodies makes easier to use them
appropriately. A few of the most common regulatory and accreditor bodies in the Sri Lankan
and global health system will be discussed under this topic.
 Ministry of Health
Ministry of Health regulates the health standards of the country. When it comes to Sri Lankan
setup the Ministry of Health plays a vital role in providing guidelines and standards to deliver
an effective healthcare over all forms of hospitals and healthcare systems. Ministry of health
serves the country holding the vision a healthier nation that contributes to its economic,
social, mental and spiritual development and the mission to contribute to social and economic
development of Sri Lanka by achieving the highest attainable health status through promote,
preventive, curative and rehabilitative services of high quality made available and accessible
to people of Sri Lanka. It serves under four objectives,
 To empower the community towards maintaining and promoting the health of its
members.
 To improve comprehensive delivery actions in available health services
 To strengthen the management functions towards the healthcare setup
 To improve the management of human resources
The ministry of health mostly aims on reducing the inequalities of healthcare and providing
an equal care to every citizen of the country. Further the system supports various health
programmes that conducted by the Department of health services and other health related
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sectors. And mainly provides technical advice in policy formulation, planning and
programming on promotion of health and to minimize inequalities among healthcare.
 National Medicines Regulatory Authority
The National Medicines Regulatory Authority (NMRA), plays an active role in health by
ensuring medicinal products are available in the country to meet the recommended standards
of safety, quality and efficacy in order to protect and improve public health. The Authority
regulates the quality of medicines, medical devices and surgical equipment, cosmetic
products and other clinical items. The National Medicines Quality Assurance Laboratory
(NMQAL), an initiative by NMRA is also functioning parallel to NMRA to ensure the
quality of medicinal and other pharmaceutical products.
NMRA is an independent authority in the Ministry of Health established in 2015 through an

Act of Parliament. It has a separate governing board which is responsible for giving the
leadership and effective advising towards the overall function of the authority while meeting
the Ministry of Health standards. The system is well consisted of an expert advisory
committee as well. Their primary objective is to increase patient access to quality-assured
medicinal and other pharmaceutical products and enhance the quality of healthcare systems
through that.
 Private Health Services Regulatory Council
Private Health Regulatory Council (PHSRC) is a Council established in 2006 by an act of

parliament in Sri Lanka. The aim of this authority is to develop and monitor the standards to
be maintained by the registered Private Medical Institutions and acts accordingly while
maintaining the expected standards. It further aims towards ensuring the minimum
qualifications for recruitment and minimum standards of training of personnel are clearly
being adopted by all the private medical institutions to give a quality patient care. The main
goal is to build up a work force of healthcare professionals in the private health care
institutions to make no difference compared to the quality of the public/government sector.
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 Centres for Medicare and Medicaid services
The centres for Medicare and Medicaid Services (CMS) is a United States federal programme
that provides a vast health coverage to more than 100 million people through Medicare,
Medicaid, the Children’s Health Insurance Programme. The aim of the CMS is to strengthen
and modernize the health care system, in order to provide access to high quality care and
improved health at a lower costs to everyone. And also it provides information to both health
care providers and consumers on how to set standards for a healthcare system based on their
published standards. The main two components of this programme are Medicare Programme
and Medicaid Programme. Medicare is an insurance programme which affords medical bills
of those who cannot afford paying. Medicaid is a healthcare assistance program which serves
low-income people in every age.
CMS introduces a set of rules and regulations that contains minimum health and safety
requirements for a hospital to have to be participated in the Medicare and Medicaid
programs. CMS is conjunction with the Hospital Quality Alliance (HQA), a private public
private collaboration on hospital performance, quality measurements and reporting.
NURSING/HEALTHCARE PERFORMANCE INDICATORS
Healthcare Performance Monitoring Indicators (HPMI) are a set of selected indicators that
are used to measure the interventions of a certain healthcare provider or a providing
institution to improve the quality, accessibility and equality of health services in the country.
In healthcare team, nurses play an important role in caring for patients. Nursing care is the
most important form of care. They are the principal caregivers in any health setup. When the
demand for the care goes up, there’s high chance for the quality to reduce.
Efforts to define the quality of nursing practice from the times of Florence Nightingale, as she
worked on improving hospital conditions and measuring the patient outcomes.
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What are nursing creative indicators?
Nursing Sensitive Indicators are considered to be used at three aspects of nursing care which
are, structure, process, and outcomes.
 Structural indicators include the supply/availability of nursing staff, the level of skills
of nursing staff, and the education levels and certification levels of nursing staff.
 Process indicators measure appropriate methods of patient assessment and nursing
interventions. Nursing job satisfaction is also considered as a process indicator which
measures the success level of the healthcare setup in another way.
 Outcome indicators reflect patient outcomes that are determined to be nursing-
sensitive because they depend on the quantity or quality of nursing care. For an
example, the level of outcome indicator measurements can be taken from the number
of pressure ulcers and falls among patients.
Other types of patient care outcome indicators have been developed to measure other
elements of medical care and are not specifically considered to be nursing-sensitive.
Examples can be taken for such indicators are maternal mortality rate, neonatal mortality rate,
hospital readmission rates and number of cardiac failure conditions presented in a year.
In 1999, the American Nurses Association (ANA) identified ten critical nursing sensitive
indicators for health care/acute settings. In 2002 the ANA added another ten indicators that
are applicable to the community-based, non-acute care settings. Since then, these indicators
have been refined and expanded several times. Mostly they were being amended yearly. The
ten original indicators that apply to hospital-based nursing care are,
 Patient satisfaction with pain management

 Patient satisfaction with nursing care
 Patient satisfaction with overall care
 Patient satisfaction with medical information provided
 Pressure ulcers
 Patient falls
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 Nurse job satisfaction

 Rates of nosocomial infections
 Total hours of nursing care per patient, per day
 Staffing mix (ratios of RNs and unregistered staff)
Nursing sensitive quality indicators are an important part of establishing evidence-based

practice guidelines. But measuring these indicators is not a simple thing as it’s an ethical
imperative. Nursing foundational principles and guidelines state that, as a profession, nursing
has a responsibility to measure, evaluate, and improve the quality of nursing practice.
Activity 2
State other healthcare performance indicators that are specifically not nursing sensitive and
their role in measuring the interventions of healthcare providers. Has a responsibility to
measure, evaluate, and improve the quality of nursing practice.
Activity 3
Compare and contrast the role of different regulatory bodies and accreditation bodies in
improving performance outcomes in healthcare in both local and global aspects.
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SUMMARY
Healthcare performance indicators are the most important factor that must be considered in
any form of healthcare providing person or a service. In this session you will come across
what is the definition for healthcare performance indicators and what do they mean, types of
healthcare performance measure, what is quality in healthcare under a historical aspect,
possible measures to enhance the quality of healthcare system, the role of regulatory and
accreditor bodies in improving performance outcomes in healthcare and finally performance
indicators for nursing care. The main aim of this session is to identify the performance
outcomes in healthcare and how to use them in your day today practices as a nurse/healthcare
provider in providing a quality patient care.
Learning Outcomes
 Define performance outcomes in health care

 Identify the healthcare outcome measures
 Define quality in nursing/healthcare
 Discuss the historical factors and background of maintaining quality in
healthcare
 Explain the effects of regulatory bodies and accreditation bodies in improving
performance outcomes in healthcare
 Describe performance indicators in nursing
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References
Roux, G., Halstead, J.A., (2009). Issues and Trends in Nursing. Canada World Health
Organization Report on Healthcare Systems (2018)
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Session 12 - Performance Outcomes in HealthCare

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Session 12 - Performance Outcomes in HealthCare

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NGU6400 – Block 01 Session 12: Performance Outcomes in HealthCare

DEFINING PERFORMANCE OUTCOMES IN HEALTHCARE

MEASURING HEALTH CARE OUTCOMES

 The number of healthy people receiving preventive health services such as

IMPORTANCE OF PERFORMANCE OUTCOMES IN NURSING

Performance outcomes stand to measure an organization’s performances or client/ patient

The history of quality measures in Nursing

 Structure, or the characteristics of health care delivery systems

Maintaining the quality in Nursing and Healthcare

REGULATORY BODIES AND ACCREDITATION BODIES IN

According to Lovern (2000) accreditation involves the certification of a program, service,

 National Medicines Regulatory Authority

NMRA is an independent authority in the Ministry of Health established in 2015 through an

 Private Health Services Regulatory Council

Private Health Regulatory Council (PHSRC) is a Council established in 2006 by an act of

 Centres for Medicare and Medicaid services

NURSING/HEALTHCARE PERFORMANCE INDICATORS

What are nursing creative indicators?

 Patient satisfaction with pain management

 Nurse job satisfaction

Nursing sensitive quality indicators are an important part of establishing evidence-based

 Define performance outcomes in health care

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