Therefore, a comprehensive evidence-based report card to evaluate the quality of nursing care was not achieved. Milbank Memorial Fund Quarterly, 44, 166-206. Quality Assessment and Documentation Burden. VBP policies are predicated on the idiom that what gets measured, gets managed. Nursing Management, 46(5), 24-32. doi:10.1097/01.NUMA.0000463882.54.082.64. doi:10.1177/1077558707299257, Needleman, J., Kurtzman, E. T., & Kizer, K. W. (2007). External forces are now facilitating this shift toward an outcome-based practice for nursing and strengthening the imperative for outcome measurement. Progress in measuring nursing outcomes. American Journal of Maternal Child Nursing, 38(5), 320. doi:10.1097/NMC.0b013e31829c0ae0. The term ‘patient outcomes’ is used frequently in healthcare research [3], [4], [5], [6]. Specific actions are needed by nurse leaders and administrators in the areas of measure selection, adoption of technology, and resource allocation. Computers in Nursing, 15(2), S82-S86. Mode of transport or transportation 4. Condition did not change and required no further care to maintain condition. Despite decades of intentional efforts to this end, the nurse contribution to patient outcomes has not been sufficiently quantified. (2014). Researchers must be willing to pursue methods beyond secondary analysis of these databases. (2001). Consequently, adoption of EHRs has increased over time (Abbass, Helton, Mhatre, & Sansgiry, 2012). Metric-driven harm: An exploration of unintended consequences of performance measurement. Nursing hours per patient day • Skill mix. Donabedian, A. The operational data set contained direct caregiver hours for each unit. A consensus report. (2011). Meaningful use and its impact on healthcare technology management. Terry L. Jones, PhD, RN Therefore, there are few elements of care that do not pass through the hands of nurses, and few outcomes that are not influenced in some way by nursing care. However, time must be expended to populate every data field created. To be useful, a measure must provide information that is actionable. The combined dependent, independent, and interdependent components of nursing practice add to this challenge (Doran, 2011). Western Journal of Emergency Medicine, 15(4), 541-547. doi:10.5811/westjem.2014.3.19658. Though highly relevant to quality assessment and self-regulation in nursing, development and routine monitoring of nurse process measures has fallen into the “too hard to do” domain. The American Recovery and Reinvestment Act of 2009 provided incentives for healthcare organizations to invest in electronic health records (McCulloch & Tegethoff, 2013). Journal of Nursing Scholarship, 36(4), 371-378. c=Military Nursing Outcomes Database (Patrician, Loan, McCarthy, Brosch, & Davey, 2010) The development of robust nurse process measures is hindered by issues related to incomplete and unstandardized documentation, documentation burden, and data collection burden. For example, the nursing intervention of surveillance does not occur in a singular space or time. New strategies to address the challenges of effective quality assessment and outcome measurement in nursing must be implemented. Therefore, nurses have a social and an economic responsibility to advocate for representation of these important patient outcomes in VBP policies, to document how nursing contributes to these outcomes, and to help organizations meet related targets. Journal of Advanced Nursing, 70(11), 2469-2482. doi:10.1111/jan.12503. Applied Nursing Research, 26, 269-272. doi:10.1016/j.apnr.2013.09.001, Raso, R. (2015). The current state of nursing performance measurement, public reporting, and value-based purchasing. Meaningful use includes the reuse of clinical and administrative data to improve the safety, quality, and access to care for patients (Westra et al., 2010). Are you part of the shift? The Expected Outcome qualifiers represent the Goal of the patient care and are documented in the future tense as: Will Improve, Will Stabilize, or Will Deteriorate whereas the Actual Outcomes qualifiers represent whether the Goals were Met or Not Met and are documented in the past tense as: Improved. Email: Tjones0222@aol.com. Washington, DC: American Nurses Publishing. The establishment of evidence-based practice competencies for practicing nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Kurtzman, E. T., O’Leary, D., Sheingold, B. H., Devers, K. J., Dwason, E. M., & Johnson, J. E. (2011). Evidence suggests that time spent on documentation increases immediately after implementation but eventually returns to baseline (Hakes & Whittington, 2008; Munyisia, Yu, & Hailey, 2011). Include measures that are sensitive to change in the aspect of care being evaluated. Worldviews on Evidence-Based Nursing, 11(1), 5–15. Hakes, B., & Whittington, J. Dubois, C. A., D’Amour, D., Pomey, M. P., Girard, F., & Brault, I. Payment incentives for adoption of EHRs stipulate that recipients demonstrate how they are using data from the EHR to improve quality. The purposes of this article are to examine the imperatives, ideal conditions, history, and challenges related to effective outcome measurement in nursing. Conceptualizing performance of nursing care as a prerequisite for better measurement: A systematic and interpretative review. Evaluating the quality of medical care. Due to the paucity of available clinical data at that time, the UHDDS was based on administrative data collected primarily for billing purposes. Vol. Not surprisingly, some nurses are unwilling to accept responsibility for outcomes over which they lack complete control. Nursing and threats to patient and nurse safety and quality of patient care. Nurses as knowledge workers: Is there evidence of knowledge in patient handoffs? Measures based on data collection methodologies intrinsic to care processes and captured by existing data systems are highly desirable. Though highly relevant to quality assessment and self-regulation in nursing, development and routine monitoring of nurse process measures has fallen into the “too hard to do” domain. Nursing care is instrumental in achieving quality outcomes for patients, families, and communities. She has been recognized as one of the Great 100 Nurses in Dallas-Ft. Worth and an Outstanding Graduate in her doctoral and undergraduate programs. However, empirical evidence to support the unique contribution of nurses to quality outcomes is currently lacking (Needleman, Kurtzman, & Kizer, 2007). Washington, DC: National Academies Press. Quality assessment and outcomes research initiatives have historically been hindered by lack of available data related to nursing processes and patient outcomes across these domains of practice. Typed versus voice recognition for data entry in electronic health records: Emergency physician time use and interruptions. VBP policies are predicated on the idiom that what gets measured, gets managed. The nurse structures were selected based on data availability and the outcomes were selected based on the strength of their theoretical link to nursing care quality. Timmers, T. K., Hulstaert, P. F., Leenen, L. P., & Luke, P. H. (2014). Consider giving an example of a time when you encountered a difficult patient and helped to improve the patient's outcome. Numerous quality assessment and performance monitoring frameworks specific to nursing now exist that propose measures sensitive to the nursing contribution to patient care (Figure). Towards evidence-based management: Creating an informative database of nursing-sensitive indicators. Willingness to Recommend Hospital to Others/Use Hospital Again, Unscheduled Physician Visits Post-Discharge, Patient Knowledge of Disease/Condition and Care Requirements, Accurate and Timely Execution of Therapeutic Interventions and Procedures, Documentation of Nursing Diagnoses, Therapeutic Objectives, and Care Given, Appropriate Use of Pharmaceutical Restraints, Death among surgical inpatients with treatable serious complications (Failure to Rescue), Catheter-associated urinary tract infections for intensive care unit patients, Central line catheter-associated blood stream infection rate for ICU and High Risk Nursery (HRN) patients, Smoking cessation counseling for heart failure, Smoking cessation counseling for pneumonia, Skill mix (RN, LVN/LPN, UAP, and contract). For example, if a patient receives an inaccurate diagnosis, unsafe accommodation, or unclear instructions for self-care, the nurse must alert the doctor or medical facility and communicate the issue. Forward, C. (2013). Western Journal of Nursing Research, 35(6), 760-794. doi:10.1177/01939549137476577, Burston, S., Chaboyer, W., & Gillespie, B. The current documentation burden in nursing is high and is a major source of job dissatisfaction among direct care nurses (Hakes & Whittington, 2008). Nursing Economic$, 33(1), 59-66. NURSING . Nursing care quality measurement. Cleanliness and quietness of the hospital environment, Fibrinolytic within 30 minutes of arrival, Controlled post-operative blood glucose in cardiac patients, Post-operative urinary catheter removed by day 2, Deep Venous Thrombosis (DVT) prophylaxis within 24 hours of surgery, Central Line Associated Bloodstream Infection (CLABSI), Catheter Associated Urinary Tract Infections (CAUTIs), Surgical Site Infections (abdominal hysterectomy and colon surgery). Quality measures are considered important to the extent that they address priority quality issues such as the IOM (2001) six aims and, in the case of nursing, the social mandate. Journal of Nursing Administration, 44(2), 79-86. doi:10.1097/NNA.0000000000000030. This action translates into a downsized nursing workforce, fewer patient services, and decreased quality of care (Kurtzman et al., 2011; Timmers, Hulstaert, & Leenan, 2014). Nurse-Sensitive Indicators Originally Identified by ANA, Assessment and Implementation of Patient Care Requirements, Ratio of RNs to Total Nursing Staff (Skill Mix of RNs, LPNs, & Unlicensed Workers), Total Nursing Care Hours Provided Per Patient (Case Mix, Acuity Adjusted), Table 2 extrapolated from Lewin-VHI (1995). However, only 15 of the proposed measures met the consensus standards for endorsement in 2004 (Table 4). At the very least, nurse administrators must request and support ongoing testing of user interface screens to maximize efficiency (Hyun, Johnson, Stetson, & Bakken, 2009). There are still relatively few scientifically acceptable measures that can reliably capture nursing's contributions to patient care. New York, NY: Oxford University Press. Performance-based payment incentives increase burden and blame for hospital nurses. Instead of continuing to search for relevance in available data, efforts must shift to making the collection of relevant data more feasible. Journal of Nursing Administration, 40(7/8), 336-343. doi: 10.1097/NNA.0b013e3181e93994. Failure to invest in data collection methodologies that yield reliable and valid measures of important nursing care processes and patient outcomes has resulted in an inadequate evidence base to support the nurse contribution to patient care. CCC of Nursing Outcomes (V2.5) consists of 528 Nursing Outcomes (176 Nursing Diagnoses with 3 outcome qualifiers: Improved, Stabilized, or Deteriorated– these 3 qualifiers are used to modify the 176 diagnoses totaling 528 Nursing Outcomes). However, technological advances and healthcare reform legislation provide new opportunities to address some of these challenges. include failure-to-rescue rates and 30-day mortality [3]. However, the act of measurement also consumes human and material resources. SNL/Ts have developed gradually over time beginning with use of the term nursing diagnosis.In a 1953 issue of the American Journal of Nursing, Fry wrote about use of nursing diagnosis as a creative approach to nursing practice. (2004). Nurses can act as mediators between patients and doctors who may have overlooked certain patient needs or solutions. National Quality Forum. Despite decades of intentional efforts to this end, nursing's contributions to patient outcomes have not been sufficiently quantified. The interventions and action types provide the evidence for measuring the outcomes. The limited range of endorsed patient outcomes is problematic. Conceptually, the most valid source of data about nursing care and patient responses to nursing care is nursing documentation. The act of measurement makes phenomena visible and functions to elevate actual and/or potential quality problems in the consciousness of stakeholders. Notably, no nurse process measures were selected for further development and none were included in the first report card. Nurses’ own recordkeeping The nursing minimum data set revisited. Nursing-sensitive indicators: A concept analysis. However, the effect of staffing and nursing education on patient outcomes, though statistically significant, is relatively small by scientific and clinical standards. This type of research falls under the umbrella of health services and/or nursing administration research which is notoriously underfunded compared to biobehavioral research (Edwardson, 2006; Holubowich & Andos, 2008; Murphy, Scott, & Warshawsky, 2014). Nursing Inquiry, 13(1), 44-51. She has completed doctoral and post-doctoral academic programs with focused study in the development and application of nurse-sensitive quality indicators. They prefer … Table 4. Examining the nursing contribution to quality patient outcomes continues to be the primary focus of her program of research. Nurse administrators should explore the feasibility of off-loading keyboard data entry to other, less costly members of the care team. Key Words: Nurse Sensitive Indicators, nursing outcomes, nursing process measures, quality assessment, quality metrics, quality measures, outcomes management, outcomes research, Minimum Nursing Data Sets, nursing taxonomy, nursing documentation system, electronic health record, value based purchasing, Meaningful Use Criteria. Ways to stay focused on your patients, not your EHR. Improving outcomes without knowledge of specific process failures is analogous to treating a disease of unknown etiology and can result in misdirected and/or delayed corrective action. The article concludes with recommendations for action to move quality assessment forward, such as substantial investment to support adequate documentation of nursing practice and patient outcomes. Dela Cruz, J. E., Shabosky, J. C., Albrecht, M., Clark, T. R., Milbrandt, J. C., Markwell, S. J., & Kegg, J. DHHS defined an MDS as the least amount of data needed to evaluate a specific service (Hobbs, 2011) and established the first MDS to evaluate hospital services in 1974: the Uniform Hospital Discharge Data Set (UHDDS). Imperatives for nurses to engage in self-regulation through quality assessment and outcomes management are stronger than ever. Treading water: The no growth investment in health services research. Doran, D. M. Figure. Examples at of Empirical Outcomes at Upstate: Plan Do Study Act (PDSA) Model used to document improvements and change; Each Upstate Nursing Unit (Inpatient & Ambulatory) has a specific report on their progress in meeting Magnet Measures. Nursing administration research. (2005). Journal of Nursing Scholarship, 42(4), 358-366. Terry L. Jones, RN, PhD is an Assistant Professor of Nursing in the Graduate Program in Nursing Administration and Healthcare Systems Management. The ANA News release (July, 6, 2020), “AMA, AHA, ANA Issue Open Letter Urging Public to Wear a Mask to Stop Covid-19 Spread” makes the case that wearing a face mask is now vital. DIAGNOSIS ----- Statement of Problem (Nursing diagnosis [NANDA List] plus etiology) NOT. Ensure continuity of care following discharge. Mac Neela, P., Scott, A., Treacy, M. P., & Hyde, A. Although nurses may contribute to a broad array of patient outcomes, the expected contribution is variable, and teasing out the unique nursing contribution to patient outcomes is difficult (Needleman et al., 2007). Outcomes are behavioral cues that will describe the patient’s responses, feelings in response to the caring interventions provided. Annals of Internal Medicine, 163, 554-556. doi:10.7326/M15-1933, Patrician, P. A., Loan, L., McCarthy, M., Brosch, L.R., & Davey, K. S. (2010). Nurse-sensitive indicators suitable to reflect nursing care quality: A review and discussion of issues. Expected Outcomes – These are the goals for the nursing care plan made. Nurse administrators also should consider allocation of additional human resources to address the documentation burden. Only one diagnosis per page . Biomedical Instrumentation & Technology, 47(1), 30-34. Their existence, challenges, and importance. The purposes of this initiative were to: identify and evaluate potential nurse sensitive indicators; explore the theoretical and empirical relationships between the identified nursing structure, process, and outcome measures; and generate a nursing report card for acute care settings (Lewin-VHI, 1995). Measuring patient outcomes results in the generation of data that can be used to improve results. Nursing report card for acute care settings. Expending resources on nursing services with no clear benefit or failing to allocate resources for nursing services with a clear benefit is not good stewardship. British Journal of School Nursing, 7(10), 490-500. Hertz, B. T. (2014). (2011). All of these databases were designed for the evaluation of nursing care in acute care hospitals, primarily on medical-surgical units. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. People or provider (e.g., nosocomial agents, staffing patterns, cognitive, affective and p… Holubowich, E. J. Montalvo, I. The profession still does not have a set of evidence-based measures that reflect the full scope of nursing services and the full continuum of outcomes sensitive to nursing care. A. Assessing the impact of an electronic medical record on nurse documentation time. This improves patient’s outcomes which has been evident in patient’s surveys as in HCAHPS survey. In this style, very little supervision is exercised by the leaders. PATIENT GOALS/ OUTCOME . Through the process of licensure, the public grants nurses the privilege to practice the art and science of nursing and in exchange, the public expects to receive quality care (ANA, 2010). Measurement is essential to quality assessment. The economic imperative to measure and manage nursing outcomes is an extension of the social contract. Securing successful funding for nursing research through the Agency for Healthcare Research & Quality. The changing reimbursement landscape: Nurses’ roles in quality and operational excellence. Therefore, surveillance cannot be conceived or measured as a discrete intervention (e.g. (1995). Thus, the social contract between health professionals and the public dictates that nurses engage in self-regulation to assure quality performance. This gain in efficiency is further enhanced when data fields are standardized across facilities and populated with a standardized taxonomy; therefore, adoption of EHRs may increase adoption of a NMDS. Quality and performance measurement: National efforts to improve quality of care through measurement development. Moreover, healthcare organizations are often hesitant to share clinical and operational data with non-employees, even for research purposes. One Expected Outcome qualifier is required for each of the 176 Nursing Diagnoses (528 possible Outcomes) to document the Goal of patient care and One Actual Outcome qualifier (528 possible Outcomes) is required to document the Result of the care. Computers in Nursing, 33(11), 487-494. doi:10.1097/CIN.0000000000000187. Sometimes surveillance is initiated by one nurse and continued by other nurses throughout an episode of care. While these tools may result in more complete documentation, they also may increase documentation burden (Cutugno et al., 2015). Gathering data to identify and examine nursing outcomes on healthcare system or patient care is now the term nursing-sensitive indicators or nurse-sensitive outcomes. (2006). Measurement of nursing outcomes is a linchpin for both of these important and interrelated activities. d=Veteran’s Administration Nursing Outcomes Database (Veteran’s Health Affairs (VHA), 2009). This ANA initiative set the course for the next two decades of activities related to quality and outcomes assessment in nursing. Quraishi, J., & Jordan, L. (2014). Instead of continuing to search for relevance in available data, efforts must shift to making the collection of relevant data more feasible. This shift will require changes in academic programs and research funding policies. Nurses are obligated to serve the public good through stewardship of health resources. Washington, DC: National Quality Forum. Medical Care Research and Review, 64(2), 44S-63S. & Andos, J. R. (2008). CCC of Nursing Outcomes (V2.5) consists of 528 Nursing Outcomes (176 Nursing Diagnoses with 3 outcome qualifiers: Improved, Stabilized, or Deteriorated– these 3 qualifiers are used to modify the 176 diagnoses totaling 528 Nursing Outcomes).They are used to depict both 1) Expected Outcomes/ Goals and 2) Actual Outcomes. Quality assessment initiatives are hindered by the paucity of available data related to nursing processes and patient outcomes across these three domains of practice. Evidence suggests that direct care nurses are skeptical about whether or not expanded VBP policies will ultimately improve quality and safety for patients, but they are confident that an expansion of quality targets will increase their documentation burden (Kurtzman et al., 2011).

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