Massachusetts Hospital Quality & Patient Safety Issue Brief Series

In 2004, the National Quality Forum endorsed a set of nursing sensitive measures, with the goal to provide hospitals, the public and purchasers with comparative measures that accurately reflect nursing performance. Massachusetts and Maine were among the first states to adopt statewide initiatives for the public reporting of nursing performance through the use of nurse sensitive measures. An INQRI team, led by Pat Noga and Barry Kitch, conducted a hospital leadership survey, including interviews with key stakeholders and hospital case studies to analyze these states' experiences implementing the initiatives. The team found that reaching agreement on the measures was a substantial and lengthy undertaking, and that while hospital leaders believed that public reporting of nurse sensitive measures was likely to have a positive impact both on the quality of nursing care and patient outcomes, they also found the initiatives to be burdensome. However, in both states, most believed that a public mandatory program would work best to improve quality of nursing care. Respondents were concerned about the accuracy and consistency of data collection and reporting across hospitals and wondered if the reports would be useful to the general public. Based on the experiences in Maine and Massachusetts, the researchers believe that it is possible to publicly report measures of nursing quality and that doing so can have a positive impact on the quality of care. The team theorizes that these initiatives are likely generalizable to other quality measurement initiatives not focused on nurse sensitive measures. The work of Noga and Kitch suggests that despite the perceived burden of implementing hospital reporting programs, public mandatory reporting may be viewed as a substantial impetus for improving the quality of nursing care.

Since completion of their study in 2008, the team has continued to educate stakeholders, mainly by creating issue briefs for their member audiences, such as the Massachusetts Hospital Association and the Organization of Nurse Leaders of Massachusetts and Rhode Island, and legislators.

Briefs include:

• Summary of Trends in Selected Nursing-Sensitive Care Measures in Massachusetts Hospitals and Related Cost Savings Estimates 
• Summary of Trends in Nurse Staffing in Massachusetts Acute Care Hospitals

This research also lives on in Massachusetts through the ongoing public reporting of various nurse sensitive measures that posted on the quality and safety website PatientCareLink. This site is a joint initiative of the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives.

NQF Webinar: What's the Easiest Way to Find and Compare NQF-Endorsed Measures?

This Friday, the National Quality Forum (NQF) will host a webinar from 1:00-2:30 p.m. ET to provide an overview of the enhanced Quality Positioning System (QPS 2.0), the most comprehensive and reliable source for finding and comparing NQF-endorsed measures. QPS 2.0 allows people to create portfolios of measures, search by inclusion in Federal reporting and payment programs, and provide feedback at any time on the measures themselves. The webinar will also discuss the new Field Guide to NQF Resources, an online tool that offers easy to understand explanations of key concepts in quality measurement and NQF’s role.

This webinar is especially relative to the work of the INQRI program. Following the 2004 publication of the NQF report, “National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set,” the Robert Wood Johnson Foundation (RWJF) convened a group of researchers and stakeholders to set priorities for the NQF-identified research agenda.  Inspired by the conversations and work of scientists and stakeholders, RWJF launched the INQRI program.  INQRI's first call for proposals was released in October 2005 and focused on measurement.

In 2006, the first round of INQRI-funded interdisciplinary teams began their research studies. These nine projects addressed three major areas: (1) investigating the link between the work of nurses and the quality of care provided in hospitals; (2) producing and validating measures that capture nurses' contributions to quality care in hospitals; and (3) evaluating the impact of innovative nurse-led initiatives on patient outcomes.

This spring, Medical Care released a special supplement which was focused entirely on the INQRI program.  Included was an article that documents INQRI's contributions to measuring nursing's impact on quality.  Click here for more details.

To learn more about some of the projects funded under that first call for proposals, check out this blog post by former INQRI National Advisory Committee member Ellen Kurtzman.

To register for the NQF webinar this Friday, please click here.

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.

Quality Measures and Nursing

Despite the $2.3 trillion spent on U.S. health care, public and private payers still have a hard time measuring whether the kind of care they are paying for is of the highest value and produces the best outcomes. Nurses represent the largest group of health care professionals in the United States and have a direct affect on patient care, yet quality measures historically have focused on treatment of conditions or diseases, not on the care delivered by nurses. That changed in 2004, when the National Quality Forum (NQF) endorsed the first set of nationally standardized performance measures to assess the quality of care provided by nurses who work in hospitals.

By focusing on patient centered outcome measures such as prevalence of pressure ulcers and falls, as well as restraint use and frequency of catheter-associated infections, the NQF began to examine the link between what nurses do and the quality of care they provide. INQRI has played an important role in adding to the evidence about the utility of the NQF-endorsed Nursing Sensitive Measures by promoting the development and testing of new measures designed to both improve care and nursing performance, as well as reduce costs.
 
Click here to download a research synthesis on this topic.

National Quality Forum Measures

Last week, Modern Healthcare reported that "The National Quality Forum is endorsing 70 performance measures that combine data from various electronic sources—such as administrative claims, pharmacy and laboratory systems, and registries—in order to advance the use of electronic data platforms to measure, report and improve quality."

Click here to read the article.

In February 2003, the National Quality Forum undertook a 14-month project to study the relationship between nursing personnel and quality, and the degree to which national voluntary consensus standards for nursing-sensitive care could be established.  The 15 indicators of nurse-sensitive care endorsed by NQF represented the first set of nationally standardized performance measures designed to assess how nurses in acute care hospitals contribute to health care quality, patient safety, and a professional and safe work environment.

This work greatly informed the development of the first INQRI call for proposals in 2005 which focused on measurement.  The teams selected via that call began their work in August 2006 and completed their work in fall 2008. The nine research projects covered three major areas: (1) investigating the link between the work of nurses and the quality of care provided in hospitals; (2) producing and validating measures that capture nurses' contributions to quality care in hospitals; and (3) evaluating the impact of innovative nurse-led initiatives on patient outcomes.

To read more about the nine teams in INQRI's first cohort, please click here.

Measuring How Nurses Contribute to Patient Safety and Health Care Quality

Update from RWJF on the Joint Commission's Work

In 2007 and 2008, the Joint Commission tested specifications for 15 "nursing sensitive" performance measures in 49 acute-care hospitals across the United States. The goal was to determine the reliability and feasibility of these measures for assessing and improving the ways nurses contribute to patient safety and health care quality.

Key Findings

• All 15 performance measures, individually and as a set, were effective in improving patient care, and hospitals could feasibly collect data on them all.
• Specifications for some of the measures needed further refinement and clarification. For example, hospitals are not consistent in the way they classify injuries from falls or how they measure the onset of infection.

Key Recommendations

• Performance measures can be strengthened and greater uniformity achieved across hospitals by clarifying the definitions of what is being assessed, refining data-collection approaches and collaborating with others to align terminology.

Funding

The Robert Wood Johnson Foundation (RWJF) supported this unsolicited project from January 2007 to December 2008 with a grant of $299,490.

(c) RWJF, 2009

INQRI's Work on the NQF-15

In INQRI's first year, our call for proposals focused on measurement, with special attention paid to the 15 nursing sensitive measures endorsed by the National Quality Forum. Several INQRI teams have examined these measures.

• Developing and Testing Nursing Quality Measures with Consumers and Patients
  Baruch College
  Led by scholars in health policy, public policy and nursing, the goal of this project was to develop nursing-sensitive quality measures that patients and other decision-makers will find important and useful. In addition to checking out, with recent patients, how they respond to existing nursing quality measures, the project also worked on new measures in an area that both patients and professionals often point to as critical: the coordination of their care. The Baruch team recently held a briefing in Washington, DC to discuss their findings. Click here for more information.

• Quality Care on Acute Inpatient Units
  The University of California, San Francisco
  The goal of this project led by a nurse scholar was to test the power of the National Quality Forum-endorsed measures to advance quality nursing research and design, test other measures as potential indicators of nursing quality, and determine the impact of nurse staffing on these indicators in specific types of patient care units.

• Validating NQF Nursing-Sensitive Performance Measures
  University of Pennsylvania
  Led by a nurse scholar, the goal of this team was to analyze and validate measures from the National Quality Forum nursing-sensitive measure set using data collected from approximately 600 acute care hospitals in three states, as well as Medicare hospital performance measures, in 2005-2006.

• Lessons Learned from State Roll-Out of the NQF Nursing Sensitive Measures
  Massachusetts Hospital Research and Education Association, Inc.
  Led by a team of health services researchers, the goal of this team was to evaluate two statewide implementations of the NQF Nursing-Sensitive Measures created to provide hospitals and the public with comparative measures of nursing quality. The two statewide implementations are a voluntary effort in Massachusetts hospitals and a government mandated effort in Maine hospitals.

• Improving the NQF Failure to Rescue Metric
  Mayo Clinic
  Led by scholars in nursing and health services research and informatics, the goal of this team was to refine one of the most controversial measures of nursing-sensitive quality of care: failure to rescue.