INVOLVING THE PUBLIC IN ASSESSING HEALTH QUALITY MEASURES - PowerPoint PPT Presentation

INVOLVING THE PUBLIC IN ASSESSING HEALTH QUALITY MEASURES

Shoshanna Sofaer, Presenter

Kirsten Firminger, Research Associate

• Project
• Research Team
• Methods
• Findings
• Implications
• The Sequel

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• “Developing and testing nursing quality measures with consumers and patients”
• Funded by the Interdisciplinary Nursing Quality Research Initiative (INQRI) of the Robert Wood Johnson Foundation
• Project had three aims; we will focus on the first: Gauge public response to 15 nursing sensitive quality measures endorsed by the National Quality Forum (NQF)

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• Shoshanna Sofaer, DrPH, Baruch College School of Public Affairs (Baruch), Principal Investigator
• Jean Johnson, PhD, RN, FAAN, George Washington University School of Medicine and Health Sciences (GW), Co-Principal Investigator
• Ellen Dawson, PhD, RN, ANP (GW), Co-Principal Investigator

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• Kirsten Firminger, doctoral candidate, (Baruch)
• Christine Pintz, PhD, RNC(GW)
• Andrea Brassard, DNSc, MPH, ANP(GW)
• Kirsten and Christine actually ran the focus groups we describe, coded the transcripts, and analyzed the quantitative and qualitative data

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• Public reporting of quality measures is on the rise, but many public reports are not looked at, not understood and not used by the intended audience
• We know that unless quality measures resonate with the public, are easy to understand and apply, they will not influence behavior
• Yet many measures that meet technical criteria have not been tested with the public

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• The National Quality Forum is a non-profit membership organization governed by multiple health care stakeholders
• They utilize a complex process to reach consensus across stakeholders on health care quality measures that meet certain criteria (next slide)
• When consensus is reached, the measures are “endorsed”
• Many major sponsors of health care quality reporting will only publicly report NQF endorsed measures, including the Centers for Medicare & Medicaid Services

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• The criteria used by NQF are:
• Importance to Measure and Report to make significant gains in healthcare quality and improve health outcomes
• Scientific Acceptability of Measure Properties, i.e. validity and reliability
• Usability by intended audiences (e.g. consumers, purchasers, providers, policy makers) i.e. can understand and would find useful in decision making
• Feasibility of data collection without undue burden

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• However, while extensive documentation is required about the scientific reliability and validity of measures, and feasibility of data collection, no documentation is required to demonstration the usability of measures to a major audience for public quality reports: consumers
• Instead, NQF relies on the views of members who are considered to be “representing” consumers, such as the AARP, the AFL-CIO, etc.

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• This research was designed to investigate the hypothesis that at least some endorsed measures are, when actually tested with consumers, less than usable
• We hoped that if our hunch proved accurate, we could use our results to influence the process by which NQF endorses measures going forward
• The focus of our work was a set of 15 measures that were endorsed by NQF as being “nursing sensitive” hospital quality measures: the NQF 15

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• We conducted 9 focus groups with recently hospitalized patients to determine if participants:
• Could understand and interpret the NQF 15
• Found these measures significant in the light of their hospital experiences
• Thought the measures related to the roles, responsibilities and functions of nurses in particular

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• Sampling:
• Three groups each in DC, Chicago and Phoenix
• Three groups each with people who used OB, medical and surgical services
• Participants recruited to vary in age, gender, race/ethnicity, education level

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• To maximize understanding of measures, we developed more user friendly language for the NQF 15 (see handout)
• To ensure comprehension of the task, we presented slides on quality measures
• To gauge understanding, we asked participants to explain the measure in their own words

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• Participants silently rated each measure on their:
• Importance
• Likelihood of variation in performance across nurses and hospitals
• Whether a very high or low score would lead them to reconsider their hospital choice
• After each rating, participants discussed their responses and reasons for their ratings in depth

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• On silent ratings, at least 80% of participants found the following measures very important:
• Failure to rescue
• Pressure ulcers
• UTI among catheterized patients
• Central line infections
• Pneumonia among patients on ventilators
• Positive nursing work environment

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• Ratings showed participants were least responsive to three measures about whether nurses advised patients to stop smoking
• Group discussion generated these reasons:
• Nurses have better things to do with their time
• Patients already know they shouldn’t smoke
• Smoking is the patient’s responsibility
• Nurses who are obviously not models of healthy behavior are not credible as messengers to adopt them

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• Many participants were ambivalent about the measures relating to falls and restraints
• Who is responsible when patients fall, the nurse or the patient?
• Don’t some patients need to be restrained?
• Do nurses sometimes restrain patients as “retribution”?
• Won’t some patients fall if they aren’t restrained?

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• Measures of nurse-patient staffing ratios, nursing mix and turnover rates, confused many
• Nursing mix: What’s good? Measure doesn’t “point to” the answer
• Nurse-patient ratio: Of great interest, but the measure was just not clear enough to consumers
• “Rate at which nursing staff voluntarily end their employment” – does this mean the turnover rate? the number of vacancies?

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• More broadly, these patients are fully aware of the centrality of nurses to their hospital experience
• They realize that in many cases, nurses share responsibility with others, including physicians and patients
• More than anything, people want the nurse to “be there” and to “be competent”
• We can’t assume consumers know the “evidence base” underlying the measures, for example that restraints actually increase rather than reduce falls

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• Does this lack of expertise mean we shouldn’t bother asking the public their views? NO!
• The public has much to contribute to assessing quality measures
• Yet at the time of the study, NQF endorsed measures even if there was no evidence of the public’s response to them

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• Getting public input before endorsement has these benefits:
• Professional judgments about the absolute and relative importance of individual measures will be either reinforced or seriously questioned
• Issues of attribution of responsibility will be surfaced
• Problems in measure specification that lead to potential confusion can be resolved

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• We can get guidance about
• When we need to explain the evidence base to “legitimate” a measure
• What kind of “contextual” information will be needed if measures are to be publicly reported
• We can learn what else the public cares about with respect to a particular issue

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• NQF always takes measures through a periodic review process; this took place in 2008-09 with the NQF 15
• We were able to present our findings in detail to NQF staff, to the Hospital Quality Alliance, as well as to many nursing and health services researcher
• As a result of this, and the review process, the smoking measures are gone, the measures the public liked most remain, and other measures are being tweaked

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• NQF has said they are moving toward changing their requirements for measures
• It remains to be seen if this will happen and what it will look like
• The good news: people involved with the review welcomed getting the kind of information we provided, and were surprised at how much it revealed
• The remaining question: no one questions spending money on statistical field testing of measures; will they find the resources to do careful consumer testing as well?

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