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Nurses: Assuring Quality Care for all Populations Leonard Davis Institute of Health Economics University of Pennsylvania

Nurses: Assuring Quality Care for all Populations

Leonard Davis Institute of Health Economics University of Pennsylvania

Mary E. Foley, MS, RN President

Nurses: Assuring Quality Care for all Populations Leonard Davis Institute of Health Economics University of Pennsylvania
Objectives • Identify concerns related to health care quality. • Define nursing’s quality indicators • Discuss

Objectives

Identify concerns related to health care quality.

Define nursing’s quality indicators

Discuss ways in which nursing’s quality indicators can be used to determine quality of care.

Objectives • Identify concerns related to health care quality. • Define nursing’s quality indicators • Discuss
Know the Cost of Everything… but the Value of Nothing Oscar Wilde

Know the Cost of Everything… but the Value of Nothing

Oscar Wilde

Know the Cost of Everything… but the Value of Nothing Oscar Wilde
The Outcomes Imperative Only about 15% of all contemporary Clinical interventions are supported by objective scientific

The Outcomes Imperative

Only about 15% of all contemporary Clinical interventions are supported by objective scientific evidence that they do more good than harm.

White, 1994

The Outcomes Imperative Only about 15% of all contemporary Clinical interventions are supported by objective scientific
Environmental Scan • Care continues to move out of the hospital into the community. • Informed

Environmental Scan

Care continues to move out of the hospital into the community.

Informed and empowered consumers of health care are concerned and are expressing those concerns.

Knowledge is being discovered at an increasing rate.

Technology continues its rapid proliferation and diffusion.

Environmental Scan • Care continues to move out of the hospital into the community. • Informed
Environmental Scan (Cont.) • Measurement of the quality of care continues to be demanded by all

Environmental Scan (Cont.)

Measurement of the quality of care continues to be demanded by all consumers.

“Corporatization” of health care continues (product lines, marketing, competition, etc.). Millions of Americans are under insured. Costs continue to drive health care.

Environmental Scan (Cont.) • Measurement of the quality of care continues to be demanded by all
Millions are Underinsured • Nearly 40 million Americans are uninsured. • More that 8 out of

Millions are Underinsured

Nearly 40 million Americans are uninsured.

More that 8 out of 10 who lack insurance are in working families.

91% of those who have private insurance get it at work.

Low-wage workers are less likely to be offered coverage at work.

Private insurance is very expensive.

Millions are Underinsured • Nearly 40 million Americans are uninsured. • More that 8 out of
Costs Drive Health Care • Premiums for employment-based insurance policies increased 11%. • The uninsured are

Costs Drive Health Care

Premiums for employment-based insurance policies increased 11%. The uninsured are often charged more for care. Health care spending per privately insured person increased 7.2% in 2000. Hospital inpatient spending increased at a rate of 2.8%. Health care affordability is deteriorating.

Costs Drive Health Care • Premiums for employment-based insurance policies increased 11%. • The uninsured are
In most instances, health care delivered to patients/clients is provided by an array of health care

In most instances, health care delivered to patients/clients is provided by an array of health care providers (occupational therapists, pharmacists, physicians, registered nurses, respiratory therapists, etc.).

In most instances, health care delivered to patients/clients is provided by an array of health care
The procedures and services currently recorded in reimbursement and utilization databases represent only a small portion

The procedures and services currently recorded in reimbursement and utilization databases represent only a small portion of the care received by the patient/client.

The procedures and services currently recorded in reimbursement and utilization databases represent only a small portion
It is vital to prove the relationship of nursing to quality care and cost efficiency in

It is vital to prove the relationship of nursing to quality care and cost efficiency in order to secure any share of future health care dollars.

It is vital to prove the relationship of nursing to quality care and cost efficiency in
Safe and Quality Patient Care Linked to Nursing Interventions

Safe and Quality Patient Care Linked to Nursing Interventions

Safe and Quality Patient Care Linked to Nursing Interventions
The focus of the health care system and health care professionals must be kept on the

The focus of the health care system and health care professionals must be kept on the client/patient, their family and their needs.

The focus of the health care system and health care professionals must be kept on the
Requires an interdisciplinary team consistently using outcomes information to make decisions in the best interest of

Requires an interdisciplinary team consistently using outcomes information to make decisions in the best interest of the patient.

Requires an interdisciplinary team consistently using outcomes information to make decisions in the best interest of
Nursing -Sensitive Indicator An indicator which is sensitive to the input of Nursing Care .

Nursing-Sensitive Indicator

An indicator which is sensitive to the input of Nursing Care.

Nursing -Sensitive Indicator An indicator which is sensitive to the input of Nursing Care .
Why do it ??? • Empirically test indicators • Build collaborative relationships with hospitals • Develop

Why do it ???

Empirically test indicators Build collaborative relationships with hospitals Develop reliable methods for data collection Engage nurses in quality-related activities Build a database for nursing-sensitive indicators Educate all consumers of care about nursing

Why do it ??? • Empirically test indicators • Build collaborative relationships with hospitals • Develop
Definitions of Quality (as it Relates to Health Care) 1920 ‑ 40 Minimum Standards 1940 ‑

Definitions of Quality

(as it Relates to Health Care)

192040

Minimum

Standards

19401960

Absence of Defects

1960

197080

Capacity Adherence

to Give Good Care

to

Standards

Definitions of Quality (as it Relates to Health Care) 1920 ‑ 40 Minimum Standards 1940 ‑
What Quality Is ... Definition of Quality in the 1990s: Meeting customers’ expectations; “Doing the right

What Quality Is ...

Definition of Quality in the 1990s:

Meeting customers’ expectations;

“Doing the right thing and doing it well” (JCAHO, 1994);

Clinically effective, efficient, and affordable health services that are delivered satisfactorily.

What Quality Is ... Definition of Quality in the 1990s: Meeting customers’ expectations; “Doing the right
Dynamic Quality Health Outcomes Model Interventions System Client Outcomes Mitchell,1997

Dynamic Quality Health Outcomes Model

Dynamic Quality Health Outcomes Model Interventions System Client Outcomes Mitchell,1997
Interventions
Interventions
Dynamic Quality Health Outcomes Model Interventions System Client Outcomes Mitchell,1997
System
System
Client
Client
Dynamic Quality Health Outcomes Model Interventions System Client Outcomes Mitchell,1997
Outcomes
Outcomes
Dynamic Quality Health Outcomes Model Interventions System Client Outcomes Mitchell,1997

Mitchell,1997

Dynamic Quality Health Outcomes Model Interventions System Client Outcomes Mitchell,1997
Indicator Selection Criteria • Specificity to nursing • Ability to be tracked • Widely regarded as

Indicator Selection Criteria

Specificity to nursing Ability to be tracked

Widely regarded as having strong link to nursing quality

Subset of indicators identified in previous work

Indicator Selection Criteria • Specificity to nursing • Ability to be tracked • Widely regarded as
Indicators • Patient-Focused Outcome • Process of Care • Structure of Care

Indicators

Patient-Focused Outcome Process of Care Structure of Care

Indicators • Patient-Focused Outcome • Process of Care • Structure of Care
Structure • Mix of RN, LPN/VN & unlicensed staff • Total Nursing Care Hours Provided per

Structure

Mix of RN, LPN/VN & unlicensed staff

Total Nursing Care Hours Provided per Patient Day

Structure • Mix of RN, LPN/VN & unlicensed staff • Total Nursing Care Hours Provided per
Process • Maintenance of Skin Integrity • Nurse Staff Satisfaction

Process

Maintenance of Skin Integrity

Nurse Staff Satisfaction

Process • Maintenance of Skin Integrity • Nurse Staff Satisfaction
Outcome Indicators • Nosocomial Infection Rate • Patient Injury Rate • Patient Satisfaction • • •

Outcome Indicators

Nosocomial Infection Rate

Patient Injury Rate

Patient Satisfaction

...

Nursing Care Pain Management Patient Education

From

Outcome Indicators • Nosocomial Infection Rate • Patient Injury Rate • Patient Satisfaction • • •

Indicators to Information

• Purpose • Policies NCNQ • Database Maintenance

Purpose

Policies

NCNQ

Database Maintenance

• Purpose • Policies NCNQ • Database Maintenance
Creating excellence by establishing a culture to build and support excellence.
Creating excellence by establishing a culture to build and support excellence.

Creating excellence by

establishing a

culture to build

and support excellence.

Creating excellence by establishing a culture to build and support excellence.
Forces of Magnetism Quality of Nursing Leadership  Leaders are perceived as knowledgeable, strong, risk- takers

Forces of Magnetism

Quality of Nursing Leadership

Leaders are perceived as knowledgeable, strong, risk- takers who follow a meaningful philosophy that is made explicit in the day-to-day operations of the department & convey a strong sense of advocacy providing staff with an overall positive sense of support

The nursing director and managers are pivotal to the success of the organization

The nursing director is critical to the development of a positive nursing situation

Forces of Magnetism Quality of Nursing Leadership  Leaders are perceived as knowledgeable, strong, risk- takers
Forces of Magnetism (cont.) Organizational Structure  The director of nursing is at the executive level

Forces of Magnetism (cont.)

Organizational Structure

The director of nursing is at the executive level of the organization, reporting directly to the chief executive officer

Decentralized departmental structures allow for a sense of control over the immediate work environment and strong nursing involvement in the committee structure across departments

With regard to staffing, quality of the staff is as important as the quantity

Forces of Magnetism (cont.) Organizational Structure  The director of nursing is at the executive level
Forces of Magnetism (cont.) Management Style  Participative management style characterized by involvement of staff at

Forces of Magnetism (cont.)

Management Style

Participative management style characterized by involvement of staff at all levels

Participation is sought, encouraged and valued; nursing administration is both visible and accessible

Communication is a two way process with active listening, direct staff input and ongoing information about what is happening within nursing and the broader organization

Forces of Magnetism (cont.) Management Style  Participative management style characterized by involvement of staff at
Forces of Magnetism (cont.) Personnel Policies and Programs  Salaries and benefits competitive  Shift rotation

Forces of Magnetism (cont.)

Personnel Policies and Programs

Salaries and benefits competitive

Shift rotation is minimized, if not eliminated, and creative and flexible staffing arrangements are tailored to meet staff needs

Significant administrative and clinical promotion opportunities exist that reward expertise with both title and salary changes

Elimination of mandatory overtime

Forces of Magnetism (cont.) Personnel Policies and Programs  Salaries and benefits competitive  Shift rotation
Forces of Magnetism (cont.) Professional Models of Care  The model of care gives the nurse

Forces of Magnetism (cont.)

Professional Models of Care

The model of care gives the nurse the responsibility and related authority for patient care

Nurses are accountable for their own practice and are coordinators of care

Forces of Magnetism (cont.) Professional Models of Care  The model of care gives the nurse
Forces of Magnetism (cont.) Quality of Care  T he nurses believe themselves to be providing

Forces of Magnetism (cont.)

Quality of Care

The nurses believe themselves to be providing high quality of nursing care to their patients

Directors of nursing and nursing management are viewed as responsible for developing the environment where such care can flourish

Forces of Magnetism (cont.) Quality of Care  T he nurses believe themselves to be providing
Forces of Magnetism (cont.) Quality Assurance  Considered a mechanism to improve quality care  Nursing

Forces of Magnetism (cont.)

Quality Assurance

Considered a mechanism to improve quality care

Nursing staff involvement in the development of the plan, implementation and data collection results in improved nursing care

Forces of Magnetism (cont.) Quality Assurance  Considered a mechanism to improve quality care  Nursing
Forces of Magnetism (cont.) Consultation and Resources  Knowledgeable experts, particularly Clinical Nurse Specialist, are available

Forces of Magnetism (cont.)

Consultation and Resources

Knowledgeable experts, particularly Clinical Nurse Specialist, are available

The magnet climate is one of peer support, both intra- and interprofessionally, and there is great awareness and appreciation of agency and community interchange of resources

Forces of Magnetism (cont.) Consultation and Resources  Knowledgeable experts, particularly Clinical Nurse Specialist, are available
Forces of Magnetism (cont.) Level of Autonomy  The nurses are permitted and expected to exercise

Forces of Magnetism (cont.)

Level of Autonomy

The nurses are permitted and expected to exercise independent judgement

Autonomy is viewed as self-determination in practicing according to professional nursing standards

Interdisciplinary decision making is essential

Forces of Magnetism (cont.) Level of Autonomy  The nurses are permitted and expected to exercise
Forces of Magnetism (cont.) Community and the Hospital  Nurses support active community outreach  Nurses

Forces of Magnetism (cont.)

Community and the Hospital

Nurses support active community outreach

Nurses want to view their hospital as a model corporate citizen

Forces of Magnetism (cont.) Community and the Hospital  Nurses support active community outreach  Nurses
Forces of Magnetism (cont.) Nurses as Teachers  Nurses place a high value on education and

Forces of Magnetism (cont.)

Nurses as Teachers

Nurses place a high value on education and teaching by nurses, not only their own personal and professional growth, but they value their roles as teachers

Nurses derive much satisfaction from teaching and it is viewed as an energizing activity

Teaching is seen as both an expectation in the profession and as an opportunity to practice as a professional

Forces of Magnetism (cont.) Nurses as Teachers  Nurses place a high value on education and
Forces of Magnetism (cont.) Image of Nursing  Nurses are professionals  Nurses are essential providers

Forces of Magnetism (cont.)

Image of Nursing

Nurses are professionals

Nurses are essential providers of health care

Forces of Magnetism (cont.) Image of Nursing  Nurses are professionals  Nurses are essential providers
Forces of Magnetism (cont.) Collegial Nurse-Physician Relationships  There is a need for mutual respect for

Forces of Magnetism (cont.)

Collegial Nurse-Physician Relationships

There is a need for mutual respect for each other’s knowledge and competence and a mutual concern for the provision of quality patient care

Nurse-Physician relationships are require constant attention and nurturing

Forces of Magnetism (cont.) Collegial Nurse-Physician Relationships  There is a need for mutual respect for
Forces of Magnetism (cont.) Orientation, inservice, continuing education, formal education and career  development Magnet facilities

Forces of Magnetism (cont.)

Orientation, inservice, continuing

education, formal education and career

development

Magnet facilities have a high emphasis on personnel growth

and development; staff development starts w/orientation & is a strong influence on retention, w/ the gradual introduction of work viewed as important

Access to inservice & continuing education related to the area of practice involved is essential; multiple opportunities exist for clinical advancement that is advancement that is competency based w/specific requirements

Forces of Magnetism (cont.) Orientation, inservice, continuing education, formal education and career  development Magnet facilities
“Quality is ballet, not hockey” Crosby, 1996

“Quality is ballet, not hockey”

Crosby, 1996

“Quality is ballet, not hockey” Crosby, 1996
“Quality is ballet, not hockey” Crosby, 1996
More Issues to Consider • Risk Adjustment for Indicators • Standardization of data collection training •

More Issues to Consider

Risk Adjustment for Indicators

Standardization of data collection training

Determination of the feasibility of using statistical methods to achieve comparability among satisfaction instruments

More Issues to Consider • Risk Adjustment for Indicators • Standardization of data collection training •
Community ‑ Based, Non ‑ Acute Care Indicators • Identification of a core set of indicators

CommunityBased, NonAcute Care Indicators

Identification of a core set of indicators

Pilot testing of the indicators

Integration of the data into a national database

Development of the risk adjustment strategy

Community ‑ Based, Non ‑ Acute Care Indicators • Identification of a core set of indicators
Community ‑ Based, Non ‑ Acute Care Indicators • Pain management • Consistency of communication •

CommunityBased, NonAcute Care Indicators

Pain management Consistency of communication Staff mix Client satisfaction Prevention of tobacco use

Cardiovascular prevention Care giver activity Identification of primary care giver ADL/IADL Psychosocial inter- action

Community ‑ Based, Non ‑ Acute Care Indicators • Pain management • Consistency of communication •
Using the cost of data collection as a reason not to collect new data is inconsistent

Using the cost of data collection as a reason not to collect new data is inconsistent with our current understanding of the cost of poor care and the imperative to measure quality of care

Using the cost of data collection as a reason not to collect new data is inconsistent
Sample Size • All Payor - More than 9.1 MILLION Patients in almost 1,000 hospitals. •

Sample Size

All Payor - More than 9.1 MILLION

Patients in almost 1,000

hospitals.

Medicare - 3.8 MILLION patients in more than 1,500 hospitals.

Nurse Staffing Data - From data sources provided by HCFA.

Sample Size • All Payor - More than 9.1 MILLION Patients in almost 1,000 hospitals. •
States Included in Data • Arizona • California • Florida • Massachusetts • Minnesota * •

States Included in Data

Arizona California Florida Massachusetts Minnesota* New York North Dakota* Texas* Virginia

Only Medicare data were available for these states

States Included in Data • Arizona • California • Florida • Massachusetts • Minnesota * •
Complications Explored • • • • • • • • Adverse drug reactions Anoxic brain damage

Complications Explored

Adverse drug reactions Anoxic brain damage Communication conditions Immediate post Partum complications Diabetic complications Joint effusion Metabolic imbalances Personal care complications

Psychiatric secondary diagnosis in non- psychiatric patients Transfusion reactions Trauma in non-trauma patients Vascular complications

Complications Explored • • • • • • • • Adverse drug reactions Anoxic brain damage
Study Findings • All analyses of the five original outcome measures (length of stay (LOS), pneumonia,

Study Findings

All analyses of the five original outcome measures (length of stay (LOS), pneumonia, post-operative infections, pressure ulcers and urinary tract infections) show statistically significant relationships with nurse staffing. That is, nurse staffing is related to the rates of the five outcomes.

. Shorter LOS is related to higher levels of overall staffing per NIW-

adjusted day.

Study Findings • All analyses of the five original outcome measures (length of stay (LOS), pneumonia,
Study Findings (Cont.) • Lower complication rates are associated with a higher mix of RNs among

Study Findings (Cont.)

Lower complication rates are associated with a higher mix of RNs among licensed nursing personnel for all four complications.

Pressure ulcers show lower rates where both staffing per acuity adjusted day and RN mix are higher.

Lower post-operative infection rates (all- payor data set only) are related to more licensed hours per NIW-

adjusted patient day.

Study Findings (Cont.) • Lower complication rates are associated with a higher mix of RNs among
Study Findings (Cont.) • Lower rates of bacterial/unspecified pneumonia complications were related to a richer staffing

Study Findings (Cont.)

Lower rates of bacterial/unspecified pneumonia complications were related to a richer staffing mix. [the one exception being with the Medicare-only data set].

Longer case-mix adjusted LOS are found in primary medical school and other teaching hospitals.

Study Findings (Cont.) • Lower rates of bacterial/unspecified pneumonia complications were related to a richer staffing
Study Findings (Cont.) • Significantly lower rates of pressure ulcers and urinary tract infections were found

Study Findings (Cont.)

Significantly lower rates of pressure ulcers and urinary tract infections were found in primary medical school hospitals.

Significantly higher rates of postoperative infections, urinary tract infections and, especially, pressure ulcers were found in hospitals located in large urban areas.

Study Findings (Cont.) • Significantly lower rates of pressure ulcers and urinary tract infections were found
Implications • Consistent relationships exist between nurse staffing, and both LOS and adverse patient outcomes. •

Implications

Consistent relationships exist between nurse staffing, and both LOS and adverse patient outcomes.

Further evidence is added to a rapidly growing body of research which demonstrates the importance of registered nurses, as well as other nursing personnel, to the prevention of adverse patient outcomes.

Implications • Consistent relationships exist between nurse staffing, and both LOS and adverse patient outcomes. •
Implications (Cont.) • Cutting staff to save money may endanger the patients’ well-being. • Cutting staff

Implications (Cont.)

Cutting staff to save money may endanger the patients’ well-being.

Cutting staff to save money may lengthen patient stays, increase complication rates and, thus, increase costs.

Nursing care CAN be quantified as a critical component of patient care and of patients’ well-being.

Implications (Cont.) • Cutting staff to save money may endanger the patients’ well-being. • Cutting staff