improving nursing sensitive patient outcomes: show me the...

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Improving Nursing Sensitive Patient Improving Nursing Sensitive Patient Outcomes: Show me the EvidenceOutcomes: Show me the Evidence

Susan L. Beck Susan L. Beck PhD APRN PhD APRN FAAN AOCNFAAN AOCN

Interim Associate Dean for Interim Associate Dean for Academic Programs Academic Programs

University of Utah University of Utah College of NursingCollege of Nursing

The day in which The day in which we talk about we talk about what we do what we do versus what we versus what we accomplish is accomplish is over. over.

It’s all about It’s all about Outcomes!Outcomes!

NursingNursing--Sensitive Patient Sensitive Patient Outcomes Outcomes

Outcomes, which focus on how patients and Outcomes, which focus on how patients and their healthcare problems are affected by their healthcare problems are affected by nursing interventions, have been identified and nursing interventions, have been identified and are described as nursingare described as nursing--sensitive patient sensitive patient outcomes. outcomes. NursingNursing--sensitive patient outcomes are those sensitive patient outcomes are those outcomes arrived at, or significantly impacted by, outcomes arrived at, or significantly impacted by, nursing interventions. The interventions must be nursing interventions. The interventions must be within the scope of nursing practice and integral within the scope of nursing practice and integral to the processes of nursing care; an empirical to the processes of nursing care; an empirical link must exist. link must exist.

NursingNursing--Sensitive Patient Sensitive Patient Outcomes Outcomes

NursingNursing--sensitive patient outcomes are sensitive patient outcomes are outcomes that are sensitive to nursing care or outcomes that are sensitive to nursing care or care rendered in collaboration with other care rendered in collaboration with other healthcare providers. healthcare providers. NursingNursing--sensitive patient outcomes represent sensitive patient outcomes represent the consequences or effects of nursing the consequences or effects of nursing interventions and result in changes in patients' interventions and result in changes in patients' symptom experience, functional status, safety, symptom experience, functional status, safety, psychological distress, and/or costs. psychological distress, and/or costs.

Why Nursing Sensitive Patient Why Nursing Sensitive Patient OutcomesOutcomes

Critical to focus on the recipient of our care

Demand for accountability and quality

Demand for safety and cost effectiveness

Sensitizes us to think about results of nursing care

Define our contributions to care – are we making a difference?

The 21The 21stst Century: The Era of Century: The Era of Accountability Accountability

Benchmarking for excellence Benchmarking for excellence CMS and Medicare reimbursement CMS and Medicare reimbursement ANA Outcomes Initiative ANA Outcomes Initiative VA Health Systems VA Health Systems NQF Nursing Outcomes NQF Nursing Outcomes ASCO Quality Initiative ASCO Quality Initiative

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Federal GovernmentFederal Government--CMSCMS

Centers for Medicare and Medicaid Centers for Medicare and Medicaid Services Services ––Medicare Hospital Quality Medicare Hospital Quality InitiativeInitiativeHospitals that submit quality info are Hospitals that submit quality info are eligible to receive full Medicare paymentseligible to receive full Medicare paymentsRollRoll--out: heart attack, heart failure, out: heart attack, heart failure, pneumoniapneumoniaPublicly available on Publicly available on HospitalCompareHospitalCompare

Federal GovernmentFederal Government--AHRQ to AHRQ to CMS CMS

The Quality Initiative: A Public Resource The Quality Initiative: A Public Resource on Hospital Performanceon Hospital Performance--voluntary participation of 3179 hospitalsvoluntary participation of 3179 hospitalsEight dimensions of patientEight dimensions of patient--centered care centered care adopted by IOMadopted by IOMHCAHPSHCAHPS--32 items..now 25 32 items..now 25

10. During this hospital stay, did you need medicine for pain? 1�� Yes 2�� No If No, Go to Question 13

11. During this hospital stay, how often was your pain well controlled? 1�� Never 2�� Sometimes 3�� Usually 4�� Always

ANA National Database of Nursing ANA National Database of Nursing Quality IndicatorsQuality Indicators--Acute Care Setting Acute Care Setting As of Nov 2004, 670 hospitals participatingAs of Nov 2004, 670 hospitals participating——8000 8000 patient unitspatient unitsIndicatorsIndicators--unit level dataunit level data–– Nursing (staff mix, hours per patient day, RN Nursing (staff mix, hours per patient day, RN

education, RN certification, % contract hours)education, RN certification, % contract hours)–– Patient (pressure ulcers, falls, patient satisfaction, Patient (pressure ulcers, falls, patient satisfaction,

nosocomial infections)nosocomial infections)–– Nurse satisfactionNurse satisfaction

University of KansasUniversity of Kansas--data warehousedata warehouseProcess to access data establishedProcess to access data established

Veteran’s Health SystemVeteran’s Health System

Integrated health information systemIntegrated health information systemPraised by IOMPraised by IOM“to collect data once at the point of care”“to collect data once at the point of care”

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VA Nursing Outcomes Database Project VA Nursing Outcomes Database Project

To benchmark local, VISN, and national patient To benchmark local, VISN, and national patient quality outcomes quality outcomes Six indicatorsSix indicators–– Nursing staff (hours per patient day, skill mix)Nursing staff (hours per patient day, skill mix)–– Patient (pressure ulcers, falls, patient satisfaction)Patient (pressure ulcers, falls, patient satisfaction)–– Nurse (satisfaction)Nurse (satisfaction)

Twelve pilot VA medical centers with acute care Twelve pilot VA medical centers with acute care bedsbeds

American Society of Clinical Oncology American Society of Clinical Oncology Quality Oncology Practice InitiativeQuality Oncology Practice Initiative

“to develop a culture of self“to develop a culture of self--examination and examination and quality improvement in practice”quality improvement in practice”Focus on processes based on guidelines Focus on processes based on guidelines Focus on private practice settingFocus on private practice settingUsed chart review with web entryUsed chart review with web entryBeta testing with guidelines providedBeta testing with guidelines providedAt ASCO session, 75% of participants indicated a At ASCO session, 75% of participants indicated a willingness to participatewillingness to participateOutcomes are part of future plans Outcomes are part of future plans

National Quality Forum National Quality Forum

National Voluntary Consensus Standards for NursingNational Voluntary Consensus Standards for Nursing--Sensitive Care: An Initial Performance Measure Set is Sensitive Care: An Initial Performance Measure Set is the firstthe first--ever national standards for nursing care. ever national standards for nursing care.

endorsed by the endorsed by the NQF’sNQF’s 250250--plus member organizationsplus member organizations

15 new standards provide a framework for how to 15 new standards provide a framework for how to measure the quality of nursing caremeasure the quality of nursing care

Next stage in outcomes measurementNext stage in outcomes measurement

15 NQF Measures15 NQF Measures1)Death among surgical inpatients with treatable serious 1)Death among surgical inpatients with treatable serious

complications (“failure to rescue”)complications (“failure to rescue”)2) Pressure ulcer prevalence2) Pressure ulcer prevalence3) Falls prevalence3) Falls prevalence4) Falls with injury4) Falls with injury5) Restraint prevalence (vest and limb only)5) Restraint prevalence (vest and limb only)6) Urinary catheter6) Urinary catheter--associated urinary tract infection for associated urinary tract infection for

intensive care unit (ICU) patientsintensive care unit (ICU) patients7) Central line catheter7) Central line catheter--associated blood stream infection associated blood stream infection

rate for ICU and highrate for ICU and high--risk nursery (HRN) patientsrisk nursery (HRN) patients8) Ventilator8) Ventilator--associated pneumonia for ICU and HRN associated pneumonia for ICU and HRN

patientspatients

15 Measures continued 15 Measures continued

9) Smoking cessation counseling for acute 9) Smoking cessation counseling for acute myocardial infarction patientsmyocardial infarction patients

10) Smoking cessation counseling for heart failure 10) Smoking cessation counseling for heart failure patientspatients

11) Smoking cessation counseling for pneumonia 11) Smoking cessation counseling for pneumonia patientspatients

12) Skill mix12) Skill mix13) Nursing care hours per patient day13) Nursing care hours per patient day14) Practice Environment Scale14) Practice Environment Scale——Nursing Work Nursing Work

Index (composite+five subscales)Index (composite+five subscales)15) Voluntary turnover15) Voluntary turnover

The explosion of databasesThe explosion of databases--exemplarsexemplars

IKnowMedIKnowMed-- oncology database that captures oncology database that captures treatment outcomes including treatment treatment outcomes including treatment response, toxicities, treatment regimen, relative response, toxicities, treatment regimen, relative dose intensity, chemo dosing, tests, lab resultsdose intensity, chemo dosing, tests, lab results

USUS OncologyOncology--network of more than 850 physicians network of more than 850 physicians at overat over 450 sites throughout the country care for 450 sites throughout the country care for more than 350,000 cancer patients a year more than 350,000 cancer patients a year --more than any other single medical organization more than any other single medical organization in the world. in the world.

CaPSURECaPSURE database 1000 urologists and patientdatabase 1000 urologists and patient--reported variables reported variables ––data from 1995data from 1995-- present present Housed at UCSF Housed at UCSF

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The SEERThe SEER--Medicare Medicare datalink datalink –– reflect the linkage of two large populationreflect the linkage of two large population--based based

sources of data that provide detailed information sources of data that provide detailed information about elderly persons with cancer. about elderly persons with cancer.

The National Health Interview Survey (NHIS)The National Health Interview Survey (NHIS)–– is an annual nationwide survey of about 36,000 is an annual nationwide survey of about 36,000

households in the U.S. households in the U.S. ----to determine knowledge, to determine knowledge, attitudes, and practices concerning cancerattitudes, and practices concerning cancer--related related health behaviors and cancer screening modalities. health behaviors and cancer screening modalities.


Home Care: OHome Care: Outcome and utcome and ASsASsessmentessmentIInformation nformation SSet (OASIS)et (OASIS)is a group of data elements that: is a group of data elements that: represent core items of a comprehensive represent core items of a comprehensive assessment for an adult home care patient; and assessment for an adult home care patient; and form the basis for measuring patient outcomes form the basis for measuring patient outcomes for purposes of outcomefor purposes of outcome--based quality based quality improvement (OBQI). improvement (OBQI).

The explosion of databasesThe explosion of databases--exemplarsexemplarsDatabases in longDatabases in long--term careterm care

Minimum Data Set (MDS)Minimum Data Set (MDS)

Online Survey, Certification and Reporting Online Survey, Certification and Reporting (OSCAR)(OSCAR)

National Nursing Home Survey (NNHS)National Nursing Home Survey (NNHS)

Medical Expenditure Panel SurveyMedical Expenditure Panel Survey--Nursing Home Component (MEPSNursing Home Component (MEPS--NHC)NHC)

Key Points Key Points Link between NSPO and qualityLink between NSPO and quality-- process and outcomesprocess and outcomes

Role of legislation, government, and private Role of legislation, government, and private organizationsorganizations

Acute care focus is now expanding to other settings Acute care focus is now expanding to other settings

Alignment of effortsAlignment of efforts

Databases are a rich resource for nursing research Databases are a rich resource for nursing research

Where is oncology nursing? Where could we be? Where is oncology nursing? Where could we be?

Did the patient achieve the desired Did the patient achieve the desired outcome? Who cares? outcome? Who cares?

LegislatorsLegislatorsPurchasersPurchasersRegulatorsRegulatorsInsurers Insurers Providers Providers ConsumersConsumers

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The Drive to be A Magnet Hospital The Drive to be A Magnet Hospital

Applicants for Magnet designation must collect Applicants for Magnet designation must collect specific nursespecific nurse--sensitive quality indicators at the sensitive quality indicators at the unit level and benchmark that data against a unit level and benchmark that data against a database at the highest/broadest level possible database at the highest/broadest level possible (i.e., national, state, specialty organization, (i.e., national, state, specialty organization, regional, or system) to support research and regional, or system) to support research and quality improvement initiatives.quality improvement initiatives.http://www.http://www.nursecredentialingnursecredentialing.org/magnet/proce.org/magnet/process.htmlss.html

Forces of Magnetism Forces of Magnetism The pivotal role of the nurse in the identification, implementatThe pivotal role of the nurse in the identification, implementation and ion and

improvement of patient or organizational processes. improvement of patient or organizational processes. . . Examples should demonstrate the staff nurse role in the process,Examples should demonstrate the staff nurse role in the process, evidence that evidence that

supports the interventions, and processes that are ongoing and ssupports the interventions, and processes that are ongoing and sustained ustained across time and practice settings.across time and practice settings.

–– How was the problem identified? How was the problem identified? –– What literature was reviewed? What literature was reviewed? –– Who was involved in the refinement of the process? Who was involved in the refinement of the process? –– How were staff involved in the decision and educated on the new How were staff involved in the decision and educated on the new process? process? –– What measures were used to demonstrate improved patient care as What measures were used to demonstrate improved patient care as a result of a result of

the new process? the new process? –– What evidence exists that these measures are ongoing and continuWhat evidence exists that these measures are ongoing and continually assessed ally assessed

by the staff for refinements and improvementsby the staff for refinements and improvements

Issues in Nursing Sensitive OutcomesIssues in Nursing Sensitive Outcomes

What outcomes should be included – develop core list and speak out

How to easily measure outcomes

How to link nursing processes with outcomes

Where, when to measure outcomes

Market our outcome contribution to care

Need to build clinical data bases documenting outcomes in terms of relevance to the health system

Which outcomes are important? Which outcomes are important?

level of nursing practice (Staff Nurse or level of nursing practice (Staff Nurse or Advanced Practice Nurse)Advanced Practice Nurse)setting (hospital, clinic, office, home care, etc.)setting (hospital, clinic, office, home care, etc.)clinical context (episode of care, continuum of clinical context (episode of care, continuum of care, etc.)care, etc.)population or type (cancer site, cancer stage); population or type (cancer site, cancer stage); and and intervention of interestintervention of interest

(Carroll & Fay, 1997; Patrick & Chiang, 2000). (Carroll & Fay, 1997; Patrick & Chiang, 2000).

Think about Lisa…Think about Lisa…1.1. Which outcomes matter? Which outcomes matter? 2.2. What types of evidence What types of evidence

would help you decide on would help you decide on what interventions might what interventions might help Lisa? help Lisa?

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ONSPO: Classification with ONSPO: Classification with ExemplarsExemplars

Symptom ExperienceSymptom ExperiencePainPainFatigueFatigueInsomniaInsomniaNauseaNauseaConstipationConstipationAnorexiaAnorexiaBreathlessnessBreathlessnessDiarrheaDiarrheaAltered Skin/mucous membranesAltered Skin/mucous membranesNeutropenia Neutropenia

http://onsopcontent.ons.org/toolkits/evidence/Clinical/http://onsopcontent.ons.org/toolkits/evidence/Clinical/outcomes.shtmloutcomes.shtml

ONSPO: A Classification with ONSPO: A Classification with ExemplarsExemplars

Functional StatusFunctional StatusADL (activities of daily living)ADL (activities of daily living)IADL (instrumental activities of daily living)IADL (instrumental activities of daily living)Role functioningRole functioningActivity toleranceActivity toleranceAbility to carry out usual activitiesAbility to carry out usual activitiesNutritional statusNutritional status



Psychological DistressPsychological DistressAnxietyAnxietyDepressionDepressionSpiritual distressSpiritual distress



Safety (Preventable adverse events)Safety (Preventable adverse events)InfectionsInfectionsFallsFallsSkin ulcersSkin ulcersExtravasation incidentsExtravasation incidentsHypersensitive reactionsHypersensitive reactions



Economic Economic Length of stayLength of stayUnexpected reUnexpected re--admissionsadmissionsEmergency visitsEmergency visitsOutOut--ofof--pocket costs (family)pocket costs (family)Cost per patient dayCost per patient dayCost per episode of careCost per episode of care

http://onsopcontent.ons.org/toolkits/evidencehttp://onsopcontent.ons.org/toolkits/evidence/Clinical/outcomes.shtml/Clinical/outcomes.shtml

Issues in Measuring Outcomes Issues in Measuring Outcomes

Timing is essential Timing is essential Short, intermediate, longShort, intermediate, long--termtermConsistent with expected effect of the Consistent with expected effect of the intervention intervention Proximate to intervention Proximate to intervention

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How to measure? How to measure?

ONS EvidenceONS Evidence--based Summariesbased Summarieshttp://onsopcontent.ons.org/toolkits/evidence/Clihttp://onsopcontent.ons.org/toolkits/evidence/Cli

nical/summaries.shtmlnical/summaries.shtml

A Web Tour of EvidenceA Web Tour of Evidence--Based Based SummariesSummaries

Symptom ExperienceSymptom ExperienceDyspneaDyspneaFatigueFatigueMucositisMucositisNausea and VomitingNausea and VomitingPainPainPeripheral NeuropathyPeripheral NeuropathySleepSleep--Wake DisturbancesWake Disturbances

Functional StatusFunctional StatusNutritional StatusNutritional StatusReturn to Usual FunctioningReturn to Usual Functioning

Safety Safety -- Preventing Adverse EventsPreventing Adverse EventsPrevention of InfectionPrevention of Infection

Psychological DistressPsychological DistressDepressionDepression

EconomicEconomic

EvidenceEvidence--based Practice based Practice

Care that integrates best scientific evidence Care that integrates best scientific evidence with clinical expertise, knowledge of with clinical expertise, knowledge of pathophysiology, knowledge of pathophysiology, knowledge of psychosocial issues, and decision making psychosocial issues, and decision making preferences of patients” preferences of patients”

(Rutledge & Grant, 2002, p.1)(Rutledge & Grant, 2002, p.1)

The Patient’s Preferences Matter The Patient’s Preferences Matter

EBP is unique because it includes the EBP is unique because it includes the preferences and values of the patient and preferences and values of the patient and family in the process. While the clinician family in the process. While the clinician may utilize the best evidence available, may utilize the best evidence available, application and outcomes will differ based application and outcomes will differ based upon the patients' values, preferences, upon the patients' values, preferences, concerns, and/or expectations. concerns, and/or expectations.

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How do you decide which How do you decide which interventions to use? interventions to use?

An Introduction to An Introduction to Sources of Sources of EvidenceEvidence

The Evidence EquationThe Evidence Equation

Clinician Experience + Clinician Experience + Patient Preferences + Patient Preferences +

Scientific Findings =Scientific Findings =Evidence Based Practice Evidence Based Practice

DepalmaDepalma, 2000, 2000

Oncology nurses have a Oncology nurses have a mandate to measure the end mandate to measure the end

results of their care and to results of their care and to improve the results over time. improve the results over time.

Given et al, 2004Given et al, 2004

Keypad Keypad In the Medicare Hospital Quality InitiativeIn the Medicare Hospital Quality Initiative

a. Hospitals are fined if they do not submit a. Hospitals are fined if they do not submit data data

b. Data are available to health professionals b. Data are available to health professionals only. only.

c. The rollc. The roll--out focused on heart attacks and out focused on heart attacks and heart failure. heart failure.

d. Nursingd. Nursing--sensitive outcomes are a main sensitive outcomes are a main focus. focus.

Keypad Keypad The ANA National Database of Nursing The ANA National Database of Nursing

Quality IndicatorsQuality Indicators

a. provides data at the patient level a. provides data at the patient level b. has been limited to the outpatient setting b. has been limited to the outpatient setting c. excludes any information about nursing c. excludes any information about nursing d. includes outcomes data from more than d. includes outcomes data from more than

8000 patient units 8000 patient units

Keypad Keypad The nursingThe nursing--sensitive outcomes included by sensitive outcomes included by

the National Quality Forum include:the National Quality Forum include:

a. Death among surgical inpatients with a. Death among surgical inpatients with treatable serious complications (“failure to treatable serious complications (“failure to rescue”)rescue”)

b. Smoking cessation counseling for lung b. Smoking cessation counseling for lung cancer patients cancer patients

c. Pain intensity c. Pain intensity d. Chemotherapy extravasations d. Chemotherapy extravasations

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Keypad Keypad The national database of interest to nursing The national database of interest to nursing

homes is:homes is:

a. a. IKnowMedIKnowMedb. OSCAR b. OSCAR c. SEER c. SEER d. d. CaPSURECaPSURE

LINKSLINKS

www.qualityforum.orgwww.qualityforum.orgwww.patientexperiencestandard.orgwww.patientexperiencestandard.orgwww.thenrcpickergroup.comwww.thenrcpickergroup.comhttp://www.cms.hhs.gov/quality/hospital/Survey2.pdfhttp://www.cms.hhs.gov/quality/hospital/Survey2.pdfhttp://appliedresearch.cancer.gov/surveys/nhis/http://appliedresearch.cancer.gov/surveys/nhis/http://healthservices.cancer.gov/seermedicare/http://healthservices.cancer.gov/seermedicare/http://www.cms.hhs.gov/oasis/hhoview.asphttp://www.cms.hhs.gov/oasis/hhoview.asphttp://http://www.www.nursecredentialingnursecredentialing.org/magnet/process.html.org/magnet/process.htmlwww.ons.orgwww.ons.org

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