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Diane K. Boyle, PhD, RN; Peggy A. Miller, PhD, RN; & Nancy Dunton, PhD University of Kansas School of Nursing Kansas City, KS. Consensus standards for Nursing-sensitive care and implications for certification. ABNS Spring Conference March 5, 2010 Costa Mesa, CA. Objectives.
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Diane K. Boyle, PhD, RN; Peggy A. Miller, PhD, RN; & Nancy Dunton, PhD University of Kansas School of Nursing Kansas City, KS Consensus standards for Nursing-sensitive care and implications for certification ABNS Spring Conference March 5, 2010 Costa Mesa, CA
Objectives • Describe the evolution of nursing-sensitive indicators. • Discuss the National Quality Forum’s development & maintenance of the National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. • Describe a model for linking nursing specialty certification with process & outcome indicators. • Indentify research linking nursing specialty certification with process & outcome measures.
Historical Context (Dawn of Nursing-Sensitive Indicators)
Genesis ofNursing-Sensitive Indicators • Late 1980s — New payment/reimbursement structures and expansion of managed care • RN jobs at risk, care compromised • 1994 — American Nurses Association (ANA) launched Patient Safety and Quality of Care Initiative • Established Panel of Experts • Commissioned a literature review to identify valid and reliable nursing-sensitive indicators
Expert Panel Findings • 1995 ANA’s Nursing Report Card for Acute Care Settings identified 21 indicators likely related to availability and quality of nurses • 10 indicators selected for development • TNHPPD*, Skill Mix, RN Satisfaction with work environment • Injury Falls, Pressure Ulcers, Nosocomial Infections, • Patient Satisfaction (nursing care, pain management, educational information, care) *TNHPPD = total nursing hours per patient day
Next Steps • 1996 — ANA funded pilot studies in 7 states to assess feasibility of data collection by nurses in hospitals: • CA, AZ, TX, ND, VA, MN, OH • 1996 – IOM released report stating there was a paucity of scientific evidence linking nursing with hospital patient outcomes (other than mortality). • 1998 — ANA issued request for proposals to develop and manage the National Database of Nursing Quality Indicators® (NDNQI®). • Provide hospitals with comparative data for quality improvement activities • Develop a national data resource for investigating the relationship between nursing and patient outcomes
NDNQI Development • 1998 — Contract awarded to Midwest Research Institute and University of Kansas School of Nursing • 1999 — First reports Issued to ~30 hospitals, almost all of whom were pilot study participants • 2010 — ~ 1570 hospitals and 15 indicators
Other HealthcareMeasurement Initiatives • CMS — Centers for Medicare and Medicaid Services (CMS), Long history of quality measurement: Care Measures • 1986 — The Joint Commission began to plan for performance measurement • 2002 Hospitals begin collecting core measures and hospital quality measures • 1993 — National Committee for Quality Assurance, HEDIS measures • 1996 – CalNOC – One of the original state pilot projects for ANA
Measurement Initiatives • 1998-2002 — Agency for Healthcare Research & Quality (AHRQ): developed Quality Indicators & Patient Safety Measures • National Quality Measures Clearinghouse (http://www.qualitymeasures.ahrq.gov/) • 1999 – National Quality Forum founded • 2007 — AHRQ launched HCAHPS (Consumer Assessment of Healthcare Providers & Systems) which includes questions on nursing • 2008, public reporting began
Quality Measurement and Consensus Standards for Nursing-Sensitive Care
Quality Measurement • What is a quality indicator? • How are measures developed and endorsed?
Key Definitions Nursing-Sensitive “…nursing-sensitive performance measures are processes and outcomes— and structural proxies for these processes and outcomes (e.g., skill mix, nurse staffing hours)—that are affected, provided, and/or influenced by nursing personnel, but for which nursing is not exclusively responsible. Nursing-sensitive measures must be quantifiably influenced by nursing personnel, but the relationship is not necessarily causal National Quality Forum: National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: 2004
Key Definitions • Quality of Care: Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine) • Indicator: Valid and reliable quantitative process or outcome measure related to one or more dimensions of performance, such as effectiveness or appropriateness (The Joint Commission)
Quality Assessment Donabedian’s Structure – Process - Outcome Antecedents Structure Process Outcome • Factors that can influence structure, process: • Environmental factors • Patient factors (also influence outcomes) Interactions between healthcare practitioner & patient Changes (desirable or undesirable) in individuals & populations Organiza-tional character-istics
Types of Quality Indicators/Measures • Structure • Process • Outcome • Use of services (used as proxy for outcome) • Efficiency/cost • Patient experience
National Quality Forum (NQF) • Private, non-profit voluntary consensus standards-setting organization • Multi-stakeholder member organization • Three-part mission to improve quality of American healthcare: • Setting national priorities and goals for improvement • Endorsing national consensus standards for measuring and publicly reporting on performance • Promoting attainment of national goals through education and outreach programs
NQF Consensus Development Process • Nine Steps • Call for Intent to Submit Candidate Standards • Call for Nominations • Call for Candidate Standards • Candidate consensus standard review • Public and member voting • Consensus Standards Approval Committee (CSAC) Decision • Board Ratification • Appeals
Original NQF Consensus Standards for Nursing-Sensitive Care (2004) Patient-Centered Outcome Measures Nursing-Centered Intervention Measures Smoking cessation*** counseling for Acute myocardial infarction Heart failure Pneumonia • “Failure to rescue”* • Pressure ulcer prevalence • Falls prevalence** • Falls with injury • Restraint prevalence (vest & limb only) • Urinary catheter-associated UTI rate (ICU)** • Central line catheter-associated blood stream infection rate (ICU & HRN)** • Ventilator-associated pneumonia rate (ICU & HRN)** System-Centered Measures • Skill mix • Nursing care hours per patient day • Practice Environment Scale - NWI • Voluntary Turnover * Death among surgical inpatients with treatable serious complications **Also an NQF-endorsed voluntary consensus standard for hospital care *** The smoking cessation standards were not re-endorsed
NQF Measure Maintenance • Annual updates provided by measure steward • Ad hoc review for evolving evidence or identified problems with measure • Routine full reviews • Moving to 3-year cycles by topic area • Meet evaluation criteria with focus on data from implementation • Harmonization with other NQF-endorsed measures • Best-in-class • Publicly reported
NQF Measure Maintenance • Notice of topic with notice of maintenance review and call for new measures • Stewards submit information demonstrating criteria are met • Reviewed by Steering Committee • Steering Committee make recommendations • If competing measures, recommend best-in-class • Public comment • NQF member voting • CSAC approval • Board ratification
Measure Evaluation Criteria • Importance to measure & report • Important to make gains in quality (e.g., safety, effectiveness, efficiency, patient-centeredness) • Evidence supports measure focus • Scientific acceptability • Specifications, reliability, validity, risk-adjustment is evidence-based, clinically meaningful differences in practice • Usability • Are results understandable and usable in decision making? • Useful for public reporting • Feasibility • By-product of care processes • Unintended consequences
Outcome or Process Measures? • Most medical indicators are process measures. • Critics say that we should measure outcomes not process • Many nursing measures are outcomes • Falls, pressure ulcers, nosocomial infections, PIV infiltrations • NQF recently suggested that outcomes should be accompanied by best practice process measures • e. g., along with fall rate: fall risk assessment and prevention protocol implementation
Absolute or Relative Measure? • Sentinel event (Absolute) • Serious, undesirable, and largely avoidable outcome • Utility of a measure that is Yes/No as opposed to a rate? • Rate-based indicators (Relative) • Patient care events expressed as a proportion or ratio
Risk Adjustment Issue • Considerations: • Adjust for differences in patient populations? • Evaluation based on providing care for population you have? • Are data available to make effective adjustment? • Is adjusted measure interpretable by users? • Risk stratification—looking within
DesirableIndicator Qualities • Covers a large segment of the patient population—a typical patient experience • Related to a costly or serious condition • Fosters quality improvement • Should not create incentive for providers to game the system (improve measures without improving quality) • Focus on interventions, not documentation • Does not focus on what’s being measured to detriment of aspects of care
Measuring QualityIs Difficult • How do we isolate nursing’s impact or contribution? • Strongly related to nursing (workforce or processes) • Many confounding factors • Characteristics or actions of the patients • Influence of other healthcare providers • Organization and environment of hospital
What model can be used for linking specialty certification with processes and outcomes?
Nurse-Sensitive Quality Care (NDNQI Conceptual Model) Patient Outcomes Structure of Care Nursing Care Processes Donabedian Model
Example Measures for Nursing-Sensitive Care Structure Process Outcome • Size • Teaching status • Payer mix • Magnet status • CNO/manager • Practice environment (e.g., autonomy) • NHPPD • Staff mix • Use of agency staff • Education • Specialty Certification • Other credentials • Turnover • Risk assessment • Implementation of prevention protocols • Pain management • Medication administration • Counseling • Communication, teamwork, decision making • Injury falls • HAPUs • Nosocomial infections • “Failure to rescue” • Mobility • Satisfaction with care • Unplanned readmissions
What research exists linking specialty certification with improved processes and outcomes?
Certification and Patient Outcomes • Nelson et al. (2007), in a study of 54 randomly selected rehabilitation units in the US found: • For every 6% increase in certified rehabilitation nurses (CRRN) on a unit, mean case-mix adjusted patient length of stay decreased by one day. • Conversely, more years experience as a rehabilitation nurse corresponded with a longer length of stay. • Lange et al. (2009) found that on units staffed with 2 or more certified nurses, there was a significantly lower fall rate than on units with one or no certified nurses. • Results were confounded by a 3-month education program on care of geriatric patients.
Certification and Patient Outcomes • Hiser et al. (2006) implemented a quality improvement program that specifically enhanced utilization of Certified Wound Ostomy Continence Nurses (CWOCN) in one medical intensive care unit and found that pressure ulcer prevalence dropped from 29% to near 0%. • Both Frank-Stromborg et al. (2002) and Coleman et al. (2009) found no difference in outcomes (e.g., management of pain & nausea) between certified and noncertified nurses.
Certification and Nursing Processes • Critical care certification was found to be associated significantly with the correct use of a pulmonary artery catheter (Iberti et al., 1994) and decision-making regarding the withholding of digitalis (Walthall et al., 1993). • In both studies certification was confounded with years of experience. • Kendall-Gallagher (2009) found the proportion of certified nurses and the rates of medication errors had no significant association via correlation or hierarchical linear model analysis.
Certification and Nursing Processes • Zulkowski, Ayello, and Wexler (2007) reported that certified wound care nurses scored wounds significantly more accurately than nurses certified in other specialties or non-certified nurses. • Using a national sample of hospitals and hierarchical linear modeling, NDNQI investigators found that nurses with wound, continence and/or ostomy certifications were significantly better at identifying (B=0.12, SE=0.03, p<0.001) and staging (B=0.13, SE=0.04, p<0.001) pressure ulcers than other nurses (Gajewski et al., 2007; Hart et al., 2006).
Research Critique • Some studies have small sample sizes and weak research designs. • Education and experience often confound the results. • Experience as certified nurse may confound the results. • RNs certified < 5 years report more autonomy, confidence, & collaboration (Cary, 2001). • Much of the research on specialty certified nurses and clinical performance is based on self-report or manager-report data. • Lacks quantitative measurement of performance • No patient outcome data • Research may been conducted in environments where few differences exist between the autonomy of certified and non-certified nurses.
Issues/Questions • Need to specify measureable processes and outcomes that each specialty certification is expected to impact, for example: • Wound, ostomy, continence: pressure ulcer assessment, pressure ulcer rate, urinary tract infections, etc. • Lactation consultants: exclusive breast milk feeding, etc. • Critical care: ventilator associated pneumonia, etc. • Are there measures that an RN with any specialty certification would impact? • Pain assessment, fall risk assessment • Many processes and outcomes need measure development
Issues/ Questions • Is certification a skill level net of education and experience or as a proxy for education & experience (they are confounded)? • Is there a combination of education and certification that effects processes and outcomes? • Example: BSN + Certification • Does certification ‘wear off’ over time? • Is there a critical prevalence of certified nurses (unit, workgroup, hospital, clinic) needed to make an impact?
Issues/Questions • The impact of specialty certification may be more difficult to capture when certified nurses: • Exist outside the usual workgroups • Are poorly utilized • Employed in units/workgroups outside their specialty certification • Have not reached a critical prevalence • RN vs ARPN certification – What are outcomes? • Level of analysis – Individual? Unit/Workgroup? Organization? Multi-level?
Snapshot of Specialty Certified Nurses from the 2009 NDNQI RN Survey
NDNQI RN Survey • RN inclusion criteria: • Full or part-time, regardless of job title • >50% of time in direct patient care • Employed a minimum of 3 months on unit • Unit based PRN or per-diem nurses employed by the hospital (agency or contract nurses are excluded)
Survey Certification Question • Specialty certification inclusion criteria: • Standards have been verified by either the American Board of Nursing Specialties or the National Organization for Competency Assessment • Are direct-care related • Are nursing certifications • 2009 data are collected on 64 specialty certifications from 18 different specialty entities
2009 RN Survey Respondents 270,423 US total survey respondents
Certifications by Specialty Entity 26.6 13.9
References • American Nurses Association (ANA). (2004). Measures and indicators that reflect the impact of nursing actions on outcomes. Scope and Standards for Nurse Administrators, 2nd Ed., Washington, DC. • Davies SM, Geppert J, McClellan M, et al. (May 2001). Refinement of the HCUP Quality Indicators. Technical Review Number 4 (Prepared by UCSF-Stanford Evidence-based Practice Center under Contract No. 290-97-0013). AHRQ Publication No. 01-0035. Rockville, MD: Agency for Healthcare Research and Quality. • Donabedian A. (1988). The quality of care: How can it be assessed? JAMA, 260,1743-1748. • Donabedian, A. (1992). The role of outcomes in quality assessment and assurance.Quality Review Bulletin, 11, 356-60. • National Quality Forum. (2004). National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC. Available at: http://www.qualityforum.org/Projects/n-r/Nursing-Sensitive_Care_Initial_Measures/Nursing_Sensitive_Care__Initial_Measures.aspx • Wunderlich GS, Sloan FA, Davis CK, eds. (1996). Nursing staff in hospitals and nursing homes: Is it adequate? Institute of Medicine, National Academy Press, Washington, DC.
Research References • Cary, A.H. (2001). Certified registered nurses: Results of the study of the certified workforce. American Journal of Nursing, 101(1), 44-52. • Coleman, E., Coon, S., Lockhart, K., Kennedy, R., Montgomery, R., Copeland, N., et al. (2009). Effect of certification in oncology nursing on nursing-sensitive outcomes. Clinical Journal of Oncology Nursing, 13(2), 165-172. • Frank-Stromborg M, Ward S, Hughes L, et al. Does certification status of oncology nurses make a difference in patient outcomes? ONF. 2002;29:665-672. • Gajewski B, Hart S, Bergquist S, Dunton N. Inter-rater reliability of pressure ulcer staging: ordinal probit Bayesian hierarchical model that allows for uncertain rater response. Statistics in Medicine. 2007;26:4602-4618. • Hart S, Bergquist S, Gajewski B, Dunton N. Reliability testing of the National Database of Nursing Quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality. 2006;21:256-265. • Hiser B, Rochette J, Philbin S, Lowerhouse N, TerBurgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy/Wound Management. 2006;52(2):48-59. • Iberti TJ, Daily EK, Leibowitz, AB, Schecter, CB, Fischer EP, Silverstein JH. Assessment of critical care nurses’ knowledge of the pulmonary artery catheter. Critical Care Medicine.1994;22:1674-1678.