Sigma Theta Tau International, Inc.Lambda Rho Chapter-at-large

Jacksonville, Florida 

2012 Nursing Research ConferenceMarch 3, 2012

Diane Brady Schwartz PhD, RN, NEA-BC

Discuss the outcomes imperative in driving professional autonomy and accountability

Examine the past, present and future of outcomes driven nursing practice

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 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

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

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)

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.

“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)

Coordinator / leader of the interdisciplinary team

Critical role in ensuring quality outcomes

Skilled/ knowledgeable in outcomes management and performance improvement ; data and data analysis

Those closest to patient care have the greatest opportunity to improve outcomes

Equal player on all key decision making committees, councils and quality activities

End result from an intervention

Measureable change

Quantifiable goal

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 ofMilitary Hospitals, and the Treatment of the Sick and Wounded in the Crimean War by Florence Nightengale.

Current databases for benchmarking outcomes:

• National Healthcare Safety Network (HAIs)

• National Database of Nursing Quality Indicators (NDNQI)

• Collaborative Alliance for Nursing Outcomes (CALNOC)

• Patient Satisfaction: Gallup, Press Ganey, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

• CMS Core Measures

• VA Nursing Outcomes Database

• National Quality Forum

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

Pediatric IV Infiltrates Pediatric Pain Assessment,

Intervention, Reassessment (AIR) Cycle Psychiatric Assault Rates

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

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

• Voluntary Turnover RN Characteristics: Education, Experience, Years of Service, Unit Rate of Admissions, Discharges

and Transfers

Process Measures• Falls & Hospital Acquired Pressure• Ulcers• Medication Administration Accuracy

Safe Practices• PICC Line Insertion Practices

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

American Nurses Credentialing Center (2008)

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

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

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

Strategic Planning Input from staff nurses Participation in committees and

councils Participation in professional

organizations Community involvement Reward and recognition

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

Demonstrates the relationship of nursing and or nursing interventions to outcomes in:

Patient care Professional practice Workplace environment Community Interdisciplinary relationships

Performance/Quality Improvement• PDCA/PDSA• Lean Six Sigma• TQM

Use of “Best Practices” and evidence

Research (qualitative or quantitative)

“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)

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

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

National Report Card for Nursing

“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….

“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)

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.

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.

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/

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

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