Nurses: Assuring Quality Care for all Populations

Leonard Davis Institute of Health Economics University of Pennsylvania

Mary E. Foley, MS, RN President

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

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 evidence that they do more good than harm. White, 1994

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 (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 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.

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.

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 Quality Patient Care Linked to Nursing 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 to make 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 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

Definitions of Quality
(as it Relates to Health Care)

1920-40 Minimum Standards

1940-1960 Absence of Defects

1960 Capacity to Give Good Care

1970-80 Adherence to 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.

Dynamic Quality Health Outcomes Model

System

Interventions

Outcomes

Client
Mitchell,1997

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

Indicators
Patient-Focused Outcome Process of Care Structure 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 Indicators
Nosocomial 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
Quality of Nursing Leadership
Leaders are perceived as knowledgeable, strong, risktakers 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 (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.)

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

Orientation, inservice, continuing education, formal education and career development Magnet facilities have a high emphasis on personnel

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

Quality is ballet, not hockey Crosby, 1996

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

Community-Based, Non-Acute 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

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 interaction

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 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.

States Included in Data

Arizona California Florida Massachusetts Minnesota* New York North Dakota* Texas* Virginia
Only Medicare data were available for these states

Complications Explored

Anoxic brain damage

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

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

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 NIWadjusted 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 (allpayor data set only) are related to more licensed hours per NIWadjusted 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.

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 (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.