The Focus on Outcomes: Evolution and Impact on Professional Nursing Practice Sigma Theta Tau International, Inc. Lambda Rho Chapter-at-large Jacksonville, Florida   2012 Nursing Research Conference March 3, 2012 Diane Brady Schwartz PhD, RN, NEA-BC

Objectives… Discuss the outcomes imperative in driving professional autonomy and accountability Examine the past, present and future of outcomes driven nursing practice

The Outcomes Imperative.. Shift in healthcare from process orientation to outcomes and performance based system National healthcare expenditures totaled $2.8 trillion in 2011 By 2020,1of every 5 dollars spent in the US is expected to go to healthcare related costs

The Outcomes Imperative.. The Commonwealth Fund (2010) study ranks the U.S. last of seven* nations overall dimensions of performance for: Access Chronic care management Healthcare system efficiency Living long, healthy lives Equity based on income levels *Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom

The Outcomes Imperative.. Medication Errors The true number of medication errors in a year is unknown because many go unreported, especially if there was no harm to the patient One estimate is that a medication error occurs in approximately 1 of every 5 doses given in hospitals; another is that 1 error occurs per patient per day 1.3 million people are injured and approximately 7000 deaths occur each year in the United States Drug-related morbidity and mortality is estimated to cost $177 billion in the United States

The Outcomes Imperative.. Affordable Care Act requires DHHS to establish a National Strategy for Quality Improvement in Healthcare. Outcome measures are included in this Strategy. In October 1, 2012, under the Affordable Care Act, Medicare will begin to reimburse hospitals based on outcomes related to patient perceptions of care, measures relating to heart attacks, heart failure, pneumonia, surgical care and health-care associated infections. (Value Based Purchasing)

What is the Role of the Nurse?

What is the Role of the Nurse? Standard 3: “The registered nurse identifies expected outcomes for a plan individualized to a patient or the situation.” American Nurses Association (2004). Scope and Standards of Nursing Practice.

What is the Role of the Nurse? “Nursing is the pivotal healthcare profession, highly valued for it’s specialized knowledge, skill and caring, in improving health status (outcomes) and ensuring safe, effective, quality care.” Nursing’s Agenda for the Future (2001)

What is the Role of the Nurse? Coordinator / leader of the interdisciplinary team Critical role in ensuring quality outcomes Skilled/ knowledgeable in outcomes management and performance improvement ; data and data analysis

What is the Role of the Nurse? Those closest to patient care have the greatest opportunity to improve outcomes Equal player on all key decision making committees, councils and quality activities

Taking a Look at Outcomes..

What is an Outcome?... End result from an intervention Measureable change Quantifiable goal

The Past… Florence Nightingale- 1854-First nurse to measure nursing outcomes by documenting that wherever nurses were; far fewer patients died, and wherever they were not, far more died. 1854- Developed the first database in nursing outcomes by detailing hospital death rates were reduced from 42% to 2.2% within six months when nursing interventions (cleanliness, wound dressing changes, bathing) were performed.1

From Florence Nightingale, Hospital Statistics and Hospital Plans, reprinted from the Transactions of the National Association for the Promotion of Social Science, Dublin Meeting, August 1861 (London, Emily Faithful & Co., 1862).

Report of the Commission Appointed to Inquire into the Sanitary Condition of the Army, the Organization of Military Hospitals, and the Treatment of the Sick and Wounded in the Crimean War by Florence Nightengale.

The Present… Current databases for benchmarking outcomes: National Healthcare Safety Network (HAIs) National Database of Nursing Quality Indicators (NDNQI) Collaborative Alliance for Nursing Outcomes (CALNOC)

The Present… Patient Satisfaction: Gallup, Press Ganey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) CMS Core Measures VA Nursing Outcomes Database National Quality Forum

National Database of Nursing Quality Indicators (NDNQI)… Proprietary database of the ANA Over 1,800 participating hospitals Benchmarks like units within a “cohort” on a quarterly basis Database for “nursing sensitive outcome indicators” Falls Pressure Ulcers Restraints

National Database of Nursing Quality Indicators (NDNQI)… Pediatric IV Infiltrates Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle Psychiatric Assault Rates

National Database of Nursing Quality Indicators (NDNQI)… RN Education and Certification RN Satisfaction Survey Skill Mix, HPPD, Turnover, Use of Agencies, Vacancy Rates Reported at the unit; service line and organizational levels

CALNOC…. Non profit registry for benchmarking unit based nurse sensitive indicators at the unit level Structural Measures Hours of Nursing Care per Patient Days • Skill Mix • Percent Contracted Hours • Ratios

CALNOC…. Voluntary Turnover RN Characteristics: Education, Experience, Years of Service, Unit Rate of Admissions, Discharges and Transfers

CALNOC.. Process Measures Falls & Hospital Acquired Pressure Ulcers Medication Administration Accuracy Safe Practices PICC Line Insertion Practices

CALNOC.. Outcome Measures Hospital Acquired Pressure Ulcer by Stage • Fall Rate and Injury Fall Rates • Restraint Prevalence Rate • Central Line-Associated Blood Stream Infections in PICC Lines • Medication Administration Accuracy Nurse Safe Practices Finding and Error Rates

Magnet Recognition Program®… American Nurses Credentialing Center (2008)

Magnet Recognition Program®… Established by the AAN following a 1983 study related to hospitals that were successful in recruitment and retention Sole recognition program that focuses on nursing excellence in an organized nursing service Currently, 391 Magnet designated facilities internationally; 387 in the US

Magnet Recognition Program®… Oversight by the American Nurses Credentialing Center 80+ Sources of Evidence Written application, manual and site visit Designation for 4 years Focus on excellence in outcomes in patient care and nursing practice

Outcomes and the Magnet Recognition Program® Designation and redesignation weighted on outcomes:** RN Satisfaction Patient Satisfaction NDNQI Clinical Indicators Falls Pressure Ulcers Restraints PIV Infiltrates, AIR cycles Education and professional certifications ** Over 24 months

Outcomes and the Magnet Recognition Program® Strategic Planning Input from staff nurses Participation in committees and councils Participation in professional organizations Community involvement Reward and recognition

Outcomes and the Magnet Recognition Program® Results of applying a Professional Practice Model Educational programs Quality Safety Use of evidence to change practice Research and evidence based practice Results of creativity and Innovation

Outcomes Evaluation… Demonstrates the relationship of nursing and or nursing interventions to outcomes in: Patient care Professional practice Workplace environment Community Interdisciplinary relationships

Processes to Improve Outcomes.. Performance/Quality Improvement PDCA/PDSA Lean Six Sigma TQM Use of “Best Practices” and evidence Research (qualitative or quantitative)

Future of outcomes.. “The future state of nursing is inextricably linked to the strides in patient care quality and safety that are critical to the success of America’s health care system, today and tomorrow”. The Joint Commission (2010)

Future of outcomes.. Pay for performance will link the financial success of the healthcare agency to outcomes Nurses must be equal players in the design of healthcare reform Greater focus on standardization of outcome measures Education of nurses will be a dominant force

Future of outcomes.. Needed competencies will include quality/performance improvement skills APRN’s will have enhanced roles in care delivery and improvement of outcomes Higher levels of advanced degrees Focus on management of chronic disease

Future of outcomes.. National Report Card for Nursing

Future of outcomes.. “The nursing profession is the largest segment of the nation’s health care workforce. Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act….

Future of outcomes.. “A number of barriers prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system. These barriers need to be overcome to ensure that nurses are well-positioned to lead change and advance health”. IOM Report on the Future of Nursing (2010)

References.. American Nurses Association. (2008). Recognizing nursing excellence: Magnet recognition program application manual. Silver Spring, MD: American Nurses Credentialing Center. American Nurses Association. (2004). Nursing: Scope and standards of practice. Washington, DC: Nursebook.org.

References.. Brown, P. (2010). Medication error prevention: A shared responsibility. Retrieved from http://www.medscape.com/viewarticle/744546. Collaborative Alliance for Nursing Outcomes. (2011). Retrieved from http://www.calnoc.org/displaycommon.

References.. Davis, K., Schoen, C., & Stremikis, K. (2010). Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally. The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/Publications/Fund-Reports/2010/Jun Healthcare.gov. (2011). The affordable care act: What is happening and when. Retrieved from http://www.healthcare.gov/law/timeline/

References.. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Stanton, M. (2011). Reducing costs in the healthcare system: Learning from what has been done. Retrieved from http://www.ahrq.gov/research/costsria/. The Joint Commission. (2010). Robert wood johnson foundation initiative on the future of nursing, at the institute of medicine. Retrieved from http://www.jointcommission.org/assets/1/18/RWJ_Future_of_Nursing.pdf

References.. Nightingale, F.(1858). Notes on matters affecting the health, efficiency, and hospital administration of the British Army. London: Harrison and Sons