1. Consensus standards for Nursing-sensitive care and implications for certification
Diane K. Boyle, PhD, RN;
Peggy A. Miller, PhD, RN; & Nancy Dunton, PhD
University of Kansas School of Nursing
Kansas City, KS
ABNS Spring Conference
March 5, 2010
Costa Mesa, CA

2. 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.

3. (Dawn of Nursing-Sensitive Indicators)
Historical Context
(Dawn of Nursing-Sensitive Indicators)

4. Genesis of Nursing-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

5. 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

6. 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

7. 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

8. Other Healthcare Measurement 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

9. Measurement Initiatives
— Agency for Healthcare Research & Quality (AHRQ): developed Quality Indicators & Patient Safety Measures
National Quality Measures Clearinghouse (
1999 – National Quality Forum founded
2007 — AHRQ launched HCAHPS (Consumer Assessment of Healthcare Providers & Systems) which includes questions on nursing
2008, public reporting began

10. Quality Measurement and Consensus Standards for Nursing-Sensitive Care

11. Quality Measurement What is a quality indicator?
How are measures developed and endorsed?

12. 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

13. 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)

14. Donabedian’s Structure – Process - Outcome
Quality Assessment
Donabedian’s Structure – Process - Outcome
Antecedents Structure Process Outcome
Factors that can influence structure, process:
Environmental factors
Patient factors (also influence outcomes)
Organiza-tional character-istics
Interactions between
healthcare practitioner & patient
Changes (desirable or undesirable) in individuals & populations

15. Types of Quality Indicators/Measures
Structure
Process
Outcome
Use of services (used as proxy for outcome)
Efficiency/cost
Patient experience

16. 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

17. 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

18. Original NQF Consensus Standards for Nursing-Sensitive Care (2004)
Nursing-Centered Intervention Measures
Patient-Centered Outcome Measures
“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)**
Smoking cessation*** counseling for
Acute myocardial infarction
Heart failure
Pneumonia
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

19. 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

20. 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

21. 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

22. Issues to Ponder

23. 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

24. 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

25. 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

26. Desirable Indicator 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

27. Measuring Quality Is 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

28. What model can be used for linking specialty certification with processes and outcomes?

29. Nurse-Sensitive Quality Care (NDNQI Conceptual Model)
Patient
Outcomes
Structure
of Care
Nursing Care
Processes
NDNQI indicators are either process, structure or outcome indicators
Donnabedian’s qi model
NOT CLINICAL
HEALTH SERVICES RESEARCH
ORGANIZATIONAL ANALYSIS
Donabedian Model

30. 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

31. What research exists linking specialty certification with improved processes and outcomes?

32. 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.

33. 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.

34. 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.

35. 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).

36. 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.

37. 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

38. 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?

39. 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?

40. Snapshot of Specialty Certified Nurses from the
2009 NDNQI RN Survey

41. 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)

42. 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

43. NDNQI Certification Question

44. NDNQI Certification Question

45. 2009 RN Survey Respondents 270,423 US total survey respondents
Category
Number
Percent
Selected a specialty
Certification
37,579
13.9
Selected ‘other’ option
8,431
3.1
Total
46, 010 17

46. Where Do Certified RNs Work?

47. Certifications by Specialty Entity
26.6
13.9

48. Q & A

49. 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 ). AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality.
 Donabedian A. (1988). The quality of care: How can it be assessed? JAMA, 260,
Donabedian, A. (1992). The role of outcomes in quality assessment and assurance. Quality Review Bulletin, 11,
National Quality Forum. (2004). National Voluntary Consensus Standards for Nursing- Sensitive Care: An Initial Performance Measure Set. Washington, DC. Available at: 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.

50. Research References
Cary, A.H. (2001). Certified registered nurses: Results of the study of the certified workforce. American Journal of Nursing, 101(1),
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),
Frank-Stromborg M, Ward S, Hughes L, et al. Does certification status of oncology nurses make a difference in patient outcomes? ONF. 2002;29:
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:
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:
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:

51. Research References
Kendall-Gallagher, D., & Blegen, M. A. (2009). Competence and certification of registered nurses and safety of patients in intensive care units. American Journal of Critical Care, 18(2),
Lange, J., Wallace, M., Gerard, S., Lovanio, K., Fausty, N., & Rychlewicz, S. (2009). Effect of an acute care geriatric educational program on fall rates and nurse work satisfaction. The Journal of Continuing Education in Nursing, 40(8),
Nelson A, Powell-Cope G, Palacios P, et al. Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehabilitation Nursing. 2007;32(5):
Walthall SA, Odtohan B, McCoy MA, Fromm B, Frankovich D, Lehmann MH. Routine withholding of digitalis for heart rate below 60 beats per minute: widespread nursing misconceptions. Heart & Lung.1993;22:
Zulkowski K, Ayello EA, Wexler S. Certification and education: do they affect pressure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.