Reflecting Back: INQRI Special Issue of Medical Care

Anne Sales PhD, RN, Deputy Editor, Medical Care

A few months ago, Medical Care published a special issue, reporting on several of the 40 projects funded through the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI) program. This edition represents a milestone in the ongoing journey of studying and reporting on the relationship between nursing care and outcomes for patients, providers, and systems of care. As the papers in this special issue highlight, there have been consistent improvements in methods and findings, leading to a better understanding of how nursing care contributes and is valued.

As this year’s AcademyHealth meeting draws near, I am reminded of my initial experience with this work. One of the gathering places for the research community where RWJF senior program officer Lori Melichar described the INQRI program in its early days was the Interdisciplinary Research Group on Nursing Issues (IRGNI), a special interest group organized through AcademyHealth. Several of the researchers on the interdisciplinary teams funded through INQRI were members of IRGNI, and used the annual IRGNI meetings at each AcademyHealth Annual Research Meeting to develop relationships and build teams. Since its inception, INQRI funded a number of highly leveraged and valuable collaborations, extending and building the community of researchers who engage in nursing health services and intervention research.

The degree to which the INQRI program has fostered a true community of researchers who are likely to continue their collaborations and research foci long after the end of the program was evident during the program’s 2012 national conference. The authors of the papers took the opportunity provided during the event to talk with each other, present their ideas to stakeholders, and use these interactions to develop their ideas.

After several months of working with the authors of each paper, and the individuals who provided valuable feedback through the review process, I think the collection of papers in this special issue achieve the purpose of celebrating the life of an important and valuable funding program, but also provide benchmarks for assessing progress in several areas of interdisciplinary research focusing on nursing care. I think it’s important to contextualize these papers in a wider context than a single funding program, no matter how valuable and important that program has been. The review of nursing research at the beginning and end of the INQRI program provides some evidence of changes over this period. However, it is important to note that similar progress can be seen in other countries and other interdisciplinary areas. The focal area of implementation research, commented on in some papers in this issue, has grown considerably over this period, and nurse researchers have continued in leading roles in this work, as they have in the period before the term “implementation research” came into wide use. INQRI’s special issue of Medical Care highlights much of this work, and introduces some new themes and findings. As implementation research grows and expands into new areas, staying current can be a challenge. I invite readers to take a look at the April special issue of the International Journal of Nursing Studies as well, to get a sense of how nurse researchers in other countries are involved in similar work, and extending our knowledge about how nursing contributes to improved services and systems around the world.

Recently, I noted that the IRGNI group has posted their agenda for the upcoming meeting. I was pleased to find that things have gone full circle, as I realized that INQRI grantee (and contributor to this special edition), Olga Yakusheva is one of the presenters. Clearly, the impact of this work continues.

New JAMA Study Underscores Why the Business Case for Nursing Is Problematic

A new study to be published tomorrow in the Journal of the American Medical Association (JAMA) finds that hospitals profit when patients have complications during surgery. According to a report in the Washington Post's Wonkblog, this counter-intuitive finding is a function of the payment structure in our nation's health care system. Hospitals earn money for every procedure done, even if that procedure is necessary to correct an error that occurs during surgery.

It's for just this reason,according to Olga Yakusheva, Douglas Wholey and Kevin Frick, that it has been so difficult to make a business case for investing in nursing care. In their article in the INQRI Medical Care supplement published last month, the INQRI researchers point out that because investments in nursing care improve patient outcomes, they hurt hospitals' bottom line. The authors go on to suggest that the roll out of the Affordable Care Act, which includes penalties for high rates of hospital acquired infections among, will help to address this confounding issue. They, like the authors of the JAMA study, also encourage taking more aggressive steps to make health care payments outcome-based, rather than service-based.

According to the Post blog, the JAMA study found that a hospital's profit margin jumped from $16,936 to $55,953 when there was a surgical complication.

Nurses Are Concerned that Patient Safety Programs Aren't Up to Par

An online survey commissioned by by the American Nurses Association finds only two in five hospital nurses in the United States, United Kingdom and China describe their hospitals as "safe."  While more than nine in ten nurses report their hospitals have safety programs, more than two in five don't believe the programs are effective. This is particularly dismaying in light of numerous efforts to improve hospital safety.

The survey is covered on the Human Capital Blog.

Also from Human Capital is a story on INQRI's contributions to interdisciplinary research into nursing as documented in Medical Care's special supplement, in the current issue of Sharing Nursing's Knowledge, out today. The story also highlights a study published in JAMA Pediatrics by Eileen Lake and Jeannette Rogowski on the impact of nurse staffing levels in neonatal intensive care units on patient outcomes.

On Jumping Off a Cliff

Lori Melichar, PhD

Seven and a half years ago, I sat down at the computer to write a speech in hopes of convincing my peers to join me in jumping off a cliff.

As a program officer for the Robert Wood Johnson Foundation (RWJF), I was excited to be involved with RWJF’s work in support of the National Quality Forum (NQF). We had partnered with the Veterans’ Administration (VA) to fund NQF in their endeavor to generate a list of nursing-sensitive measures. The resulting report was the inspiration for the Interdisciplinary Nursing Quality Research Initiative (INQRI) program, an enterprise of which I am incredibly proud.

So, why the cliff?

At the time, many thought that the pursuit of research linking nursing to quality should be exclusively in the purview of nurse researchers.

But, I’m not a nurse researcher. I’m not even a nurse; I’m a labor economist who, way back in the fall of 2005, was relatively new to the field. However, as my work with RWJF and NQF evolved, I began to appreciate not only the plethora of gaps in what we knew about nursing, but also the role of nurses as valued team members.

When I began collaborating with Mary Naylor and Mark Pauly on brainstorming ideas for what would ultimately become the INQRI program, we settled on one thing at the outset: INQRI would not fund research that was solely conducted by nurses. We believed then and we believe now that interdisciplinary research allows researchers to break out of their siloes, develop new ideas, test old assumptions, and pursue an understanding of the issues facing us with strong methodological fervor.

INQRI’s Focus on Dissemination and Implementation

Marita G. Titler, PhD, RN, FAAN, Deleise S. Wilson, PhD, RN, Barbara Resnick, PhD, CNRP, FAAN, Leah L. Shever, PhD, RN 

With our paper, “Dissemination and Implementation: INQRI’s Potential Impact,” we explored the implementation strategies, challenges, and lessons learned from conducting five INQRI funded implementation studies. We also presented two case examples of other INQRI studies to illustrate dissemination strategies. We repeatedly saw that INQRI teams used common implementation strategies across studies which addressed education, ongoing interaction with sites, use of implementation tools, and visibility of the projects on the study units. However, many studies experienced some challenges with institutional review board reviews. Several of the PIs were concerned about the short-time dedicated to the actually implementation phase of the research. Despite this challenge, the teams found that success in the engagement of site coordinators and nurses involved with their projects and the development of tools for other hospitals to use for improving practice. We would encourage researchers interested in pursuing dissemination and implementation projects to focus on understanding the importance of context, as well as the complexity of implementation, and ensuring good communication with clinicians and study sites.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Prepping the Manuscripts - Videos from INQRI's National Conference

As we mentioned in Monday's first post, the papers published in the Medical Care supplement were presented during last April's INQRI national conference.  This gave our authors the opportunity to get feedback on their manuscripts and incorporate the advice offered by members of INQRI's leadership team, National Advisory Committee, fellow grantees, stakeholder guests, and colleagues from the Robert Wood Johnson Foundation.  These videos allow you to look back at these discussions and understand the evolution of these articles.






This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

A Continuing Collaboration

Randall Krakauer, MD 

Five years ago there was considerably less attention paid to the issue of readmissions than is the case today. Mary Naylor, Mark Pauly and the University of Pennsylvania team had already demonstrated the potential to reduce 90 day readmissions through better management of the discharge process, including the period immediately after discharge. Our team at Aetna was busy building Medicare care management infrastructure to impact chronic illness and Advanced Illness at the intersection of quality and cost - and had already seen a reduction in avoidable admissions and readmissions through telephonic case management. We needed to know whether there was incremental opportunity with on-site and home care management. So began a very productive collaboration that continues. Our program began with collaboration with Mary, Mark, and their team on Aetna Medicare Advantage members in metropolitan Philadelphia, with a Transitional Care program, measured against a clinically matched group in another region. With the demonstration of a 20% reduction in 90-day readmissions (publication 1), and considerable cost savings (impact at the intersection of quality and cost) we began building Transitional Care programs that are now nationwide. With the increased importance of Star Rating measures for Medicare programs, this experience has served us well. Such programs are still being expanded, but they are part of comprehensive care management programs everywhere - it is no longer necessary to demonstrate their value.

My collaboration with Mary, Mark, and their team has also led me to another venture: my role on the National Advisory Committee (NAC) for the Interdisciplinary Nursing Quality Research Initiative (INQRI) program. Since joining the NAC in 2006, I have been pleased to review research proposals, advise funded grantees on their project plans, and offer advice and support to Mary and Mark as they lead this impressive program. Like Aetna’s work with the Penn team, INQRI teams have continually shown the value of nurse-led interventions.

Our work and collaboration on reducing readmissions has been very productive and valuable. But since we don't actually achieve Nirvana in this world, this work and collaboration will continue, and we expect to continue pushing the limits of our potential. Similarly, I look forward to seeing the continued impact that I know INQRI teams will have on improving healthcare quality.

Dr. Krakauer is the National Medical Director for Aetna Medicare and a member of INQRI’s National Advisory Committee. 

1) Naylor, M; Bowles, K; McCauley, K; Maislin, G; Pauly, M; Krakauer, R: "High Value Transitional Care: Translation of Research into Practice." J. Eval. Clin. Practice. 16 March 2011, 1-7.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

How my INQRI Grant Has Had an Impact on My Work

Susan Letvak PhD, RN, FAAN

Since completing my INQRI research, “The Effects of Nurse Presenteeism on Quality Care and Patient Safety,” in 2010, I believe the importance of nurse health has received much needed national and international attention. A healthy nursing workforce is not only important to the profession, but also to quality of patient care and hospital costs. We have received requests to share the survey our interdisciplinary team developed from researchers throughout the United States, as well as Australia, the Philippines, Trinidad, Iceland, and South Africa. Recently our study has received attention from other health care professions and we have also received requests for our survey tool from dental hygienists and physical therapists. Importantly, I have been actively consulting with hospitals throughout North Carolina on addressing nurses’ health concerns, especially mental health and the high rates of nurse depression identified in our study. I am now working towards researching interventions that will improve nurse health, which will ultimately improve quality of care and patient safety and decrease health system costs.

On a personal note, I have received unexpected recognition because of our study results. After publishing our findings in high impact nursing journals, I was interviewed by health care writers throughout the country. Our study findings were presented in a NY Times blog, in hospital administrator newsletters, and in specialty nursing group newsletters. I have been an invited speaker for large nursing groups, including the British Columbia Nurses Union, and OR Nurse Managers, as well as for numerous regional and local nursing organizations. I was also interviewed for a live NPR program. Finally, I believe my INQRI grant was instrumental in my being selected as a Fellow in the Academy of Nursing, a life-long career goal which I did not expect to achieve for several more years.

I would not have developed such a successful interdisciplinary team without the support and funding from the RWJF INQRI program. The findings from our study have the potential to not only improve the health of nurses, but also to improve quality of care while decreasing hospital costs. They have laid the foundation for future work which will provide guidance to hospital systems on ensuring a healthy nursing workforce as well as provide the support for needed policy change.

Dr. Letvak is an Associate Professor and Chair of Adult Health Nursing at the University of North Carolina Greensboro. 

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival. 

Facilitators and Challenges to Conducting Interdisciplinary Research

Cynthia F. Corbett, PhD, Linda L. Costa, PhD, Michele C. Balas PhD, William J. Burke, MD, E. Robert Feroli, PharmD, Kenn B. Daratha, PhD 

With our paper, “Facilitators and Challenges to Conducting Interdisciplinary Research,” we described the lessons learned from selected INQRI studies to demonstrate nurses’ contributions to high-functioning, patient-centered teams to improve the safety, quality and cost-effectiveness of health care. We believe that the complex issues challenging the U.S. health care system require interdisciplinary solutions, but that perceived barriers exist to the conduct of this type of inquiry. However, INQRI teams showed that there are several facilitators to promote interdisciplinary research including funding streams, demonstrated benefits, and policy trends that are promoting interprofessional education and practice. We found that interdisciplinary research can create synergistic relationships to produce outcomes that are greater than those that could be realized by single disciplinary research. But, to do so, barriers to interdisciplinary research must be overcome. We recommend that researchers employ these strategies to overcome these barriers: 1) garner strong support from institutional leaders at all phases of the research project; 2) communicate effectively; and 3) implement effective models of leadership.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

INQRI Demonstrates Lessons Learned, Recommendations for the Future

José A. Pagán, PhD 

This special issue of Medical Care nicely summarizes many of the key accomplishments of the INQRI program in terms of pushing the frontier of what is known about the linkages between nursing care and health care quality.

INQRI not only has provided resources for nursing researchers to show the role of nursing care on the delivery of high quality health care services, but the program has also increased awareness about the importance of nursing care in the research conducted in other disciplines.

The provision of financial and technical resources through the INQRI program to make interdisciplinary work possible has brought together researchers from different disciplines (economics, business, engineering and many others) that typically would have not thought about getting involved in nursing research. I suspect some of this is due to the lack of a scholarly community large enough to sustain high impact conversations and policy discussions about the role of nurses in health care quality. INQRI has taken us a step closer to having a critical mass of interdisciplinary nursing researchers.

The methodological challenges in implementation science may seem large but the work funded by INQRI in this area shows clear lessons learned and provides recommendations to advance methods, including the need to develop standards for implementation methods as well as identifying the potential benefits of thinking about reporting standards.

Dr. Pagán is a Professor and Chair of the Department of Health Management & Policy in the School of Public Health at the University of North Texas Health Science Center at Fort Worth and a member of INQRI's National Advisory Committee. 

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival. 

Methodology Issues in Implementation Science

Robin Newhouse, PhD, RN, NEA-BC, FAAN, Kathleen Bobay, PhD, RN, NEA-BC, Patricia C. Dykes, DNSc, RN, FAAN, FACMI, Kathleen R. Stevens, EdD, RN, ANEF, FAAN, Marita Titler, PhD, RN, FAAN 

In our article, “Methodology Issues in Implementation Science,” we identified some of the methodological challenges experienced by INQRI teams in the conduct of their projects and provided recommendations for future methods development. Although evidence-based practices improve patient outcomes, they are often underused for a number of health conditions. This underuse adds to the proliferation of unexplained and unjustified variations in practices and we believe that implementation science holds promise for expanding what is known about improving health care delivery, outcomes, and value. Based on the four INQRI case studies we reviewed, we recommend the following strategies to advance methods in implementation science: 1) the development of a core set of implementation concepts and metrics; 2) the creation of standards for implementation methods; and 3) the endorsement of reporting standards for implementation studies. Implementation science is the link between effective interventions, practice, and patient outcomes. To generate usable knowledge needed to leverage health system change and realize broad health care improvements, the methodological issues identified must be addressed to build implementation science.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Sharing the Road with Friends

Lynne Garner, PhD

As a funder of research that will “promote practical benefit for improving health,” Donaghue has an uphill road to climb. Sure, competently and ethically funding research is a big job, but it’s one that I think we’ve done fairly well. But funding the type of research that will lead to actually improving health and healthcare? Now that’s a far greater challenge.

As we work on this challenge, partnering with others who share this same passion is a real help. Though INQRI and Donaghue each have their own ways of developing new knowledge and learning how that knowledge can make an impact, we’ve found several ways to work together on those goals:

Host a Funders Form – The question of why knowledge from research doesn’t more readily get used by health care providers, systems and consumers is too frequently laid at the doorstep of researchers and their institutions. Certainly, there are a lot of answers to be found there, such as poorly aligned rewards and the heavily-resourced intervention being tested that can’t be sustained without a research grant. But funders need to look at themselves for answers, too. What expectations do we require or discourage that later impacts implementation? Are funding cycles too short to make a real impact? Do we focus on research that is more theory-driven than reality-driven? These are some of the themes explored during a two-day forum of over 20 funders hosted by INQRI and Donaghue in 2009.

Use Stakeholders – And speaking of how funders can shape their programs to enhance the uptake of research findings, INQRI was an innovator in requiring their researchers to work with practice and policy stakeholders through the course of the research project and beyond. The impact of these stakeholder’s perspectives is clear when INQRI researchers describe their work. Learned from INQRI’s example, Donaghue has incorporated stakeholders in our programs and review panels.

Try Out New Research Models – One of Donaghue’s goals is to work with others to test new ideas in grantmaking and health research. So we were delighted when RWJF and INQRI asked us to join the Future of Nursing Funders’ Community. By using an online portal and quick review of the proposals’ match with the program requirements, the community increases the efficiency of researchers applying for funds and of grantmakers looking to identify relevant opportunities.

A journey is always better if you can share the road with a friend, and Donaghue thanks INQRI for their work on these important issues. Donaghue welcomes - and I’ll bet INQRI does, too - others who want to work on them with us.

Lynne Garner, PhD, is the President and Trustee for the Donaghue Foundation. 

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Reflections on INQRI's Work

This video provides an overview of the impact INQRI has had on the delivery of high quality care.  Please watch this video to learn more about the type of work INQRI has funded since its inception and comment below with your thoughts.

   

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

The Challenging Business Case When Spending More on Nurses Improves Quality

Mark V. Pauly, PhD

There is considerable evidence, based on both common sense and rigorous research supported by the INQRI program, that what nurses do or do not do, in hospitals and in other heath care settings, can influence the quality of care. Clinical measures like fall rates and pain control, consumer satisfaction measures, and continuity of care can often be improved by new programs that change what nurses do. Some (though by no means all) of those programs themselves require new upfront resources—planning and training at a minimum, and often more nurse work hours at higher skill levels. But, as is so common in health care, knowledge that there is a way to improve quality does not mean that the new ways will be adopted. Inertia and organizational factors get in the way, but so does the need to provide a financial rationale for deploying more new resources.

Sometimes the hard message of economics gives bad news: just because something improves quality is not sufficient for it to be desirable if the value of the increment in quality is not large enough to justify the additional cost it entails. And proving that the improvement is (or is not) worth the cost is both challenging and politically delicate. But even when a more costly program would pass the cost-benefit test, can we be confident that hospitals, other health care providers, or insurers public or private will pay for those costs? The answer so far, in many cases, is that the financial or business justification is hard to see and hard to implement. Why is this so, will it always be this way, and what might be done about it?

Existing Evidence of the Business Case for Investments in Nursing Care

Olga Yakusheva, PhD, Douglas Wholey, PhD, Kevin D. Frick, PhD

In our article, “What Can We Learn from the Existing Evidence of the Business Case for Investments in Nursing Care: Importance of Content, Context, and Policy Environment,” we used evidence generated through INQRI funded research to illustrate where the business case for nursing investments stands now and to discuss factors that may limit transferring that knowledge into clinical practice. We found that most of the studies were unable to capture spill-over and dynamic effects. Therefore, the existing business case for nursing investments is likely understated. As a result, organizations could forfeit potentially viable nursing investments that may improve long-term financial stability. We also saw that a fragmented health care delivery system could lead to the financial benefits of a nursing investment accruing outside of the organization originally incurring the costs. Organizations may conclude that implementing potentially quality-improving and cost-saving nursing interventions would be financially unattractive. However, payment reform, with its emphasis on high-quality affordable patient-centered care, is likely to strengthen the business case for nursing. Working on this project leads us to conclude that future efforts should employ methodologically rigorous approaches that focus on societal implications of investments in nursing care, combined with an understanding of potential barriers and facilitators of nursing change.

Bottom line: Healthcare reform and emphasis on cost-effective centered patient approach will strengthen the business case for nursing investments.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Linkages between Nursing and the Quality of Patient Care: A Two Year Comparison

Mary D. Naylor, PhD, RN, FAAN, Ellen M. Volpe, PhD, RN, Adam Lustig, MS,  Heather J. Kelley, MA, Lori Melichar, PhD, Mark V. Pauly, PhD

To address a critical lack of evidence regarding nursing’s contribution to the delivery of high quality care, INQRI’s leadership team conducted a literature review designed to analyze peer-reviewed papers that addressed the relationships between nursing and the quality of patient care. This review focuses on literature published in 2004 (pre-INQRI) and 2009 (5-years post-INQRI’s launch) to evaluate the advances in this important line of inquiry and identify the potential contributions of the INQRI program.

The search identified 389 studies (161 in 2004; 228 in 2009), which examined the relationship between nursing and patient care quality. The number of published papers in all categories of study designs – non-experimental, quasi-experimental and experimental – increased between the years 2004 and 2009. The body of evidence regarding linkages between nursing and quality of care has increased in the depth of science, as seen in higher rates and quality of publications, enhanced methodological rigor, and evidence of stronger interdisciplinary collaboration. While INQRI’s contribution to this expanded body of knowledge is unclear, the evidence supports the increased importance of the program’s goal of measuring and enhancing nursing’s contributions to the quality of patient care.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

INQRI's Legacy

Susan B. Hassmiller, PhD, RN, FAAN 

As the Robert Wood Johnson Foundation’s senior adviser for nursing and a nurse myself, I am well aware of nurses’ contributions to improving patient care. I also know that nurses have the potential to vastly improve the health and safety of their patients, and their contributions increase if they have more education, autonomy, and support. INQRI developed the rigorous evidence base that supports what I, RWJF’s leaders, and many others have known for years: the link between nursing and high-quality patient care is real and tangible.

The legacy of INQRI includes a lasting impact on RWJF’s nursing work, as well as on health care research, delivery and systems across the country. INQRI studies have informed the work of Future of Nursing: Campaign for Action, an important and ambitious national initiative of AARP, the AARP Foundation and RWJF to transform health care through nursing. The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, which provides the evidence-based recommendations that drive the Campaign, featured the work of three outstanding INQRI teams.

Gerri Lamb, PhD, RN, FAAN and Francois Sainfort, PhD developed a staff nurse care coordination model that features six nurse care coordination activities regularly performed by staff nurses in hospital settings as part of their daily activities.

David Thompson, DNSc, MN, RN, Jill Marsteller, PhD, MPP, and J. Bryan Sexton, PhD conducted the first randomized, controlled clinical trial to reduce central-line-associated blood stream infections among ICU patients. They found that substantial reductions in infections can be widely achieved, especially when nurses lead patient safety efforts.

Linda Flynn, PhD, RN, FAAN and Dong-Churl Suh, PhD linked a core cluster of nurse safety processes to fewer medication errors. Their findings supported the importance of positive work environment on patient outcomes.

After the IOM report was released, the Foundation immediately began focusing on implementation, and we turned to INQRI for the additional evidence we needed to guide that work. We know INQRI is a model in using interdisciplinary research teams to conduct rigorous studies that provide evidence to shape change. We also took a lesson from INQRI’s playbook in launching our state Action Coalitions, requiring them to focus on interdisciplinary collaboration and partnerships to achieve their goals. Now nursing Action Coalition leaders are partnering with other health professionals, consumers, philanthropies, the business community, payers, and government to transform nursing and improve patient care.

INQRI has made truly invaluable contributions to all of this work. Its grantees have demonstrated that nurses are involved at all levels of care and have positive contributions to make in every setting. Because of evidence they provided, we know that a different kind of health care system is possible. It is possible to reduce the number of patients who suffer bloodstream infections or pressure ulcers. It is possible to reduce hospital readmissions and to improve care coordination. It is possible to measure patients’ pain more accurately and treat it more effectively, and it is possible to avoid medication errors. And now we know that nurses make those things possible. Now, that’s a legacy.

Dr. Hassmiller joined the Robert Wood Johnson Foundation in 1997 and is presently the Foundation's senior adviser for nursing. In this role, she shapes and leads the Foundation’s strategies to address nurse and nurse faculty shortages in an effort to create a higher quality of patient care in the United States. Drawn to the Foundation’s “organizational advocacy for the less fortunate and underserved,” Hassmiller is helping to assure that RWJF's commitments in nursing have a broad and lasting national impact.  

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

INQRI: A Focus on Measurement

Ellen T. Kurtzman, MPH

Since its inception, INQRI has funded rigorous research to develop, test, and improve performance measures that capture nurses' contributions to high quality, cost-effective care.  From the beginning, program support emphasized projects that would contribute to the science of nursing and inform key priority areas for which no measures--or inadequate measures--existed.

For example, INQRI grantees Shoshanna Sofaer, DrPH and Jean Johnson, PhD, FAAN conducted focus groups with recently hospitalized patients to understand their perception of the NQF nursing sensitive measures.  Participants found several patient safety measures to be compelling and clearly believed that nurses had a significant role in hospital quality. However, they did not think nurses should be advising patients to quit smoking, arguing that nurses have better things to do with their time. In part because of this research, NQF dropped smoking-cessation counseling for myocardial infarction, heart failure and pneumonia from the nursing-sensitive measures.

Grantees Marcelline Harris, PhD, RN and Jack Needleman, PhD, FAAN focused their INQRI project on refining one of the most controversial measures of nursing-sensitive quality of care: failure to rescue. Their team developed three revised failure to rescue measures, one based on discharge data where the diagnosis was not coded as "present on admission" and two based on data where the diagnosis was coded as "present on admission."

Sean Clarke, PhD, CRNP, FAAN, Doug Sloane, PhD, and their INQRI team analyzed how a number of the NQF nursing sensitive measures track with each other. For example, the team wanted to uncover if staffing and practice environment measures could predict the quality of care received by patients.  Researchers merged survey data and patient outcomes data from about 600 hospitals in three states with new performance measures disseminated by the Centers for Medicare & Medicaid Services on the Hospital Compare website.

Of course, these are just three examples of the impact that INQRI programs have had in the field of measurement....there are many more that have made lasting contributions.  Certainly, as implementation of the Affordable Care Act proceeds and as health care continues to be more transparent and accountable, providers, payers, health care practitioners, and policymakers will need to draw from the rich work of these investigators and the INQRI legacy.

Ellen T. Kurtzman is assistant research professor in the School of Nursing at The George Washington University. For nearly a decade, she has been working in the field of patient safety and health care quality. Prior to her arrival at GW, she was the architect of National Quality Forum-endorsed™ (NQF) consensus standards for measuring nursing’s contribution to quality. While at NQF, Ms. Kurtzman also led national efforts to establish hospital and home health care quality and performance standards. In advancing these causes, she has published and presented on nursing performance measurement, public reporting, and quality issues. She is also a former member of INQRI’s National Advisory Committee.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

Measuring Nursing’s Impact on Quality

Susan Beck, PhD, Marianne E. Weiss, DNSc, Nancy Ryan-Wenger, PhD, Nancy E. Donaldson, DNSc, Carolyn Aydin, PhD, Gail L. Towsley, PhD, William Gardner, PhD

In our article, “Measuring Nurses’ Impact on Health Care Quality:Progress, Challenges and Future Directions,” we summarized the research generated by four INQRI teams and reflected on the challenges and future directions related to improving quality measurement.  INQRI researchers have addressed the need for quality measures that are useful across populations including pain, falls, pressure ulcers, restraint use, medication administration accuracy, bloodstream infections, discharge preparation and perceptions of daily nursing care.  These teams tested new ways to model the relationships between structure, process, and outcome; addressed the continuum from hospital to home, measuring the role of discharge preparation on readmissions and emergency department visits.  Most of the measures tested focused on the positive aspects of what nurses do: believing the patient’s pain, providing daily comfort care, and preparing patients to go home after a hospitalization.  We found that several challenges exist relative to quality measurement, including measuring care delivery from multiple perspectives, determining the dose of care delivered, and measuring the entire care process.  Future work should focus on the development of simple, feasible, affordable measures that can be integrated in the care delivery system.

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.

What Did We Find?

This video gives an overview of all of the articles in the new supplement of Medical Care... check it out!

 

This post is part of our week-long blog carnival focused on the Medical Care supplement.  Click here to access all posts in this carnival.