Nurses: Assuring Quality Care for all Populations

1. Nurses: Assuring Quality Care for all Populations Leonard Davis Institute of Health Economics University of Pennsylvania Mary E. Foley, MS, RN President

2. 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.

3. Know the Cost of Everything…but the Value of Nothing Oscar Wilde

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.).

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

11. 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.

12. Safe and QualityPatient Care Linked toNursing Interventions

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

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

17. Nursing-Sensitive Indicator An indicator which is sensitive to the input of Nursing Care.

18. 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

19. Definitions of Quality(as it Relates to Health Care) 1920‑40 1940‑1960 1960 1970‑80 Minimum Absence of Capacity Adherence Standards Defects to Give to Good Care Standards

20. 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.

22. 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

23. Indicators • Patient-Focused Outcome • Process of Care • Structure of Care

24. Structure • Mix of RN, LPN/VN & unlicensed staff • Total Nursing Care Hours Provided per Patient Day

25. Process • Maintenance of Skin Integrity • Nurse Staff Satisfaction

26. Outcome Indicators • Nosocomial Infection Rate • Patient Injury Rate • Patient Satisfaction • Nursing Care • Pain Management • Patient Education • ...From Indicators to Information

27. NCNQ • Purpose • Policies • Database Maintenance

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Forces of Magnetism (cont.) Community and the Hospital • Nurses support active community outreach • Nurses want to view their hospital as a model corporate citizen

39. 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

40. Forces of Magnetism (cont.) Image of Nursing • Nurses are professionals • Nurses are essential providers of health care

41. 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

42. 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

44. 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

45. 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

46. 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

47. 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

48. 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.

49. States Included in Data • Arizona • California • Florida • Massachusetts • Minnesota* • New York • North Dakota* • Texas* • Virginia • Only Medicare data were available for these states