Nurses: Assuring Quality Care for all PopulationsLeonard Davis Institute of Health EconomicsUniversity of Pennsylvania

Mary E. Foley, MS, RNPresident

Objectives

Identify concerns related to health care quality.Define nursings quality indicatorsDiscuss ways in which nursings quality indicators can be used to determine quality of care.

Know the Cost of Everythingbut the Value of Nothing

Oscar Wilde

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

Environmental ScanCare 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 (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.

Millions are UnderinsuredNearly 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.

Costs Drive Health CarePremiums 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.

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.).

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

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.

Safe and QualityPatient Care Linked toNursing Interventions

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

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

Nursing-Sensitive Indicator

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

Why do it ???Empirically test indicatorsBuild collaborative relationships with hospitalsDevelop reliable methods for data collectionEngage nurses in quality-related activitiesBuild a database for nursing-sensitive indicatorsEducate all consumers of care

about nursing

Definitions of Quality(as it Relates to Health Care)

192040 19401960 1960 197080 Minimum Absence ofCapacity Adherence Standards Defects to Give to Good Care Standards

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.

Indicator Selection Criteria

Specificity to nursingAbility to be trackedWidely regarded as having strong link to nursing qualitySubset of indicators identified in previous work

Indicators

Patient-Focused OutcomeProcess of CareStructure of Care

Structure

Mix of RN, LPN/VN & unlicensed staff

Total Nursing Care Hours Provided per Patient Day

Process

Maintenance of Skin Integrity

Nurse Staff Satisfaction

Outcome IndicatorsNosocomial Infection Rate

Patient Injury Rate

Patient Satisfaction Nursing Care Pain Management Patient Education...From Indicators to Information

NCNQ

Purpose

Policies

Database Maintenance

Creating excellence by establishing a culture to build and support excellence.

Forces of Magnetism

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

Quality of Nursing Leadership

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.)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.)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.)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.)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 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.)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.)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.)Community and the Hospital Nurses support active community outreach

Nurses want to view their hospital as a model corporate citizen

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.)Image of Nursing Nurses are professionals

Nurses are essential providers of health care

Forces of Magnetism (cont.)Collegial Nurse-Physician Relationships There is a need for mutual respect for each others 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.)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

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

CommunityBased, NonAcute Care IndicatorsIdentification of a core set of indicatorsPilot testing of the indicatorsIntegration of the data into a national databaseDevelopment of the risk adjustment strategy

CommunityBased, NonAcute Care IndicatorsPain managementConsistency of communicationStaff mixClient satisfactionPrevention of tobacco use

Cardiovascular preventionCare giver activityIdentification of primary care giverADL/IADLPsychosocial inter-action

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

Sample SizeAll Payor - More than 9.1 MILLIONPatients 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.

States Included in DataArizonaCaliforniaFloridaMassachusettsMinnesota*New York North Dakota*Texas*VirginiaOnly Medicare data were available for these states

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

Study FindingsAll 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 (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 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.)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.

ImplicationsConsistent 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 (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.