Presentation on theme: "Diane K. Boyle, PhD, RN; Peggy A. Miller, PhD, RN; & Nancy Dunton, PhD"— Presentation transcript:
1 Consensus standards for Nursing-sensitive care and implications for certification Diane K. Boyle, PhD, RN;Peggy A. Miller, PhD, RN; & Nancy Dunton, PhDUniversity of Kansas School of NursingKansas City, KSABNS Spring ConferenceMarch 5, 2010Costa 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 careRN jobs at risk, care compromised1994 — American Nurses Association (ANA) launched Patient Safety and Quality of Care InitiativeEstablished Panel of ExpertsCommissioned a literature review to identify valid and reliable nursing-sensitive indicators
5 Expert Panel Findings1995 ANA’s Nursing Report Card for Acute Care Settings identified 21 indicators likely related to availability and quality of nurses10 indicators selected for developmentTNHPPD*, Skill Mix, RN Satisfaction with work environmentInjury Falls, Pressure Ulcers, Nosocomial Infections,Patient Satisfaction (nursing care, pain management, educational information, care)*TNHPPD = total nursing hours per patient day
6 Next Steps1996 — ANA funded pilot studies in 7 states to assess feasibility of data collection by nurses in hospitals:CA, AZ, TX, ND, VA, MN, OH1996 – 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 activitiesDevelop a national data resource for investigating the relationship between nursing and patient outcomes
7 NDNQI Development1998 — Contract awarded to Midwest Research Institute and University of Kansas School of Nursing1999 — First reports Issued to ~30 hospitals, almost all of whom were pilot study participants2010 — ~ 1570 hospitals and 15 indicators
8 Other Healthcare Measurement Initiatives CMS — Centers for Medicare and Medicaid Services (CMS), Long history of quality measurement: Care Measures1986 — The Joint Commission began to plan for performance measurement2002 Hospitals begin collecting core measures and hospital quality measures1993 — National Committee for Quality Assurance, HEDIS measures1996 – CalNOC – One of the original state pilot projects for ANA
9 Measurement Initiatives — Agency for Healthcare Research & Quality (AHRQ): developed Quality Indicators & Patient Safety MeasuresNational Quality Measures Clearinghouse (http://www.qualitymeasures.ahrq.gov/)1999 – National Quality Forum founded2007 — AHRQ launched HCAHPS (Consumer Assessment of Healthcare Providers & Systems) which includes questions on nursing2008, 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 causalNational Quality Forum: National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: 2004
13 Key DefinitionsQuality 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 AssessmentDonabedian’s Structure – Process - OutcomeAntecedents Structure Process OutcomeFactors that can influence structure, process:Environmental factorsPatient factors (also influence outcomes)Organiza-tional character-isticsInteractions betweenhealthcare practitioner & patientChanges (desirable or undesirable) in individuals & populations
15 Types of Quality Indicators/Measures StructureProcessOutcomeUse of services (used as proxy for outcome)Efficiency/costPatient experience
16 National Quality Forum (NQF) Private, non-profit voluntary consensus standards-setting organizationMulti-stakeholder member organizationThree-part mission to improve quality of American healthcare:Setting national priorities and goals for improvementEndorsing national consensus standards for measuring and publicly reporting on performancePromoting attainment of national goals through education and outreach programs
17 NQF Consensus Development Process Nine StepsCall for Intent to Submit Candidate StandardsCall for NominationsCall for Candidate StandardsCandidate consensus standard reviewPublic and member votingConsensus Standards Approval Committee (CSAC) DecisionBoard RatificationAppeals
18 Original NQF Consensus Standards for Nursing-Sensitive Care (2004) Nursing-Centered Intervention MeasuresPatient-Centered Outcome Measures“Failure to rescue”*Pressure ulcer prevalenceFalls prevalence**Falls with injuryRestraint 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 forAcute myocardial infarctionHeart failurePneumoniaSystem-Centered MeasuresSkill mixNursing care hours per patient dayPractice Environment Scale - NWIVoluntary 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 stewardAd hoc review for evolving evidence or identified problems with measureRoutine full reviewsMoving to 3-year cycles by topic areaMeet evaluation criteria with focus on data from implementationHarmonization with other NQF-endorsed measuresBest-in-classPublicly reported
20 NQF Measure Maintenance Notice of topic with notice of maintenance review and call for new measuresStewards submit information demonstrating criteria are metReviewed by Steering CommitteeSteering Committee make recommendationsIf competing measures, recommend best-in-classPublic commentNQF member votingCSAC approvalBoard ratification
21 Measure Evaluation Criteria Importance to measure & reportImportant to make gains in quality (e.g., safety, effectiveness, efficiency, patient-centeredness)Evidence supports measure focusScientific acceptabilitySpecifications, reliability, validity, risk-adjustment is evidence-based, clinically meaningful differences in practiceUsabilityAre results understandable and usable in decision making?Useful for public reportingFeasibilityBy-product of care processesUnintended consequences
23 Outcome or Process Measures? Most medical indicators are process measures.Critics say that we should measure outcomes not processMany nursing measures are outcomesFalls, pressure ulcers, nosocomial infections, PIV infiltrationsNQF recently suggested that outcomes should be accompanied by best practice process measurese. 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 outcomeUtility 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 experienceRelated to a costly or serious conditionFosters quality improvementShould not create incentive for providers to game the system (improve measures without improving quality)Focus on interventions, not documentationDoes 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 factorsCharacteristics or actions of the patientsInfluence of other healthcare providersOrganization 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) PatientOutcomesStructureof CareNursing CareProcessesNDNQI indicators are either process, structure or outcome indicatorsDonnabedian’s qi modelNOT CLINICALHEALTH SERVICES RESEARCHORGANIZATIONAL ANALYSISDonabedian Model
30 Example Measures for Nursing-Sensitive Care Structure Process OutcomeSizeTeaching statusPayer mixMagnet statusCNO/managerPractice environment (e.g., autonomy)NHPPDStaff mixUse of agency staffEducationSpecialty CertificationOther credentialsTurnoverRisk assessmentImplementation of prevention protocolsPain managementMedication administrationCounselingCommunication, teamwork, decision makingInjury fallsHAPUsNosocomial infections“Failure to rescue”MobilitySatisfaction with careUnplanned 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 CritiqueSome 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 performanceNo patient outcome dataResearch may been conducted in environments where few differences exist between the autonomy of certified and non-certified nurses.
37 Issues/QuestionsNeed 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 assessmentMany processes and outcomes need measure development
38 Issues/ QuestionsIs 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 + CertificationDoes certification ‘wear off’ over time?Is there a critical prevalence of certified nurses (unit, workgroup, hospital, clinic) needed to make an impact?
39 Issues/QuestionsThe impact of specialty certification may be more difficult to capture when certified nurses:Exist outside the usual workgroupsAre poorly utilizedEmployed in units/workgroups outside their specialty certificationHave not reached a critical prevalenceRN 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 careEmployed a minimum of 3 months on unitUnit 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 AssessmentAre direct-care relatedAre nursing certifications2009 data are collected on 64 specialty certifications from 18 different specialty entities
49 ReferencesAmerican 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.aspxWunderlich 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 ReferencesCary, 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 ReferencesKendall-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.