Palliative Study Identifies Best Measures of Quality Care

A recent study out of the University of Rochester seeks to identify the best available set of measures to evaluate whether facilities are delivering the highest quality service possible to palliative care and hospice patients, and their families, Epoch Times reports.

The study, “Measuring What Matters,” was led by Sally Norton, associate professor in nursing and palliative care at the University of Rochester. It narrows down 10 “Measures That Matter” from a list of 75 indicators, based on what’s most important to patients and families. They include:

• Comprehensive assessment, including physical, psychological, social, spiritual, and functional screening soon after admission;
• Screening for pain, shortness of breath, nausea, and constipation during admission;
• Documented discussion regarding emotional needs and spiritual concerns; 
• Documentation of their preferences for life-sustaining treatments; and
• Adherence to documented preferences to withhold or withdraw life-sustaining treatments.

Researchers for the study, which was published in the Journal of Pain and Symptom Management, chose scientifically rigorous measures that: were meaningful for patients and their families; are able to be implemented by providers; and that can significantly improve the level of care. Researchers hope that this study will eventually create health care benchmarks for the industry.

Norton and her colleagues also recommend developing a method for identifying all patients who could benefit from palliative and hospice care, and developing a survey for patients or their families that is valid in all settings.

The INQRI-funded “Nursing's Specific Contributions to Quality Palliative Care within the Context of Interdisciplinary Intensive Care Practice” explored the relationships between quality palliative nursing care delivered in intensive care units (ICUs) and patient and family outcomes. It also explored how to measure and to improve these outcomes. The purpose of this investigator-initiated study was to examine nursing's specific contributions to quality palliative care provided to patients and their families in the ICU. This interdisciplinary team was led by Lissi Hansen and Richard Mularski.

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.

New INQRI Article on the Failure to Rescue Metric

INQRI researchers Marcelline Harris, Jack Needleman, and their team recently published a new piece in Medical Care, focused on their project, "Improving the National Quality Forum (NQF) Failure to Rescue Metric."  The team's goal was to refine one of the most controversial measures of nursing-sensitive quality of care: failure to rescue.

The new article examines whether the accuracy of failure to rescue exclusion rules can be improved with data with good "present on admission" indicators. The authors concluded that failure to rescue is a robust quality measure, sensitive to nursing across alternative exclusion rule specifications.

Click here to learn more.

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: 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.

INQRI Grantee on the Importance of Transforming the U.S. Health System

Continuing INQRI's contribution to RWJF's Human Capital blog carnival on "Health Care in 2013," INQRI grantee Robin Newhouse's post was featured today. Dr. Newhouse details her resolution for the U.S. in 2013: that the country "begin the transformation of health care systems to enhance high quality patient-centered care." Her post focuses on the importance of implementing evidence-based practices and the measurement and improvement of patient outcomes.

Click here to read Dr. Newhouse's piece.

A New Tool to Compare Hospital Performance

Last week, Tom Avril and Dylan Purcell, of the Philadelphia Inquirer, reported on the Center of Medicare & Medicaid Services' hospital performance measurements for Philadelphia area hospitals. The Inquirer has created its own health portal for Philadelphia area residents to obtain performance data on eight serious, generally preventable conditions that may influence which facility they chose to obtain health services from when necessary.


Click here to access the Philadelphia Inquirer's hospital performance data.

Click here to read the news article regarding hospital performance measurements.

Click here to read more about INQRI teams' work addressing quality/performance measurement.

Click here to access the CMS hospital compare website.

Patients' Top Marks Don't Always Equal Safe Care

A new article in USA Today explains that the newspaper's analysis of new Medicare data suggests that patients' perceptions of the quality if their care in hospitals differs from what is shown by more objective measures like readmission rates and deaths.

The article discusses the fact that more than 120 hospitals which were very well-reviewed by patients for providing excellent care conversly have high death rates related to heart failure, pneumonia and heart attacks.

Click here to read the article.

Health Affairs Article: "A Road Map For Improving The Performance Of Performance Measures"

This week, we'll be highlighting papers published in the new edition of Health Affairs, entitled "Still Crossing the Quality Chasm." This edition explores the question of quality as raised in the 2001 Institute of Medicine report, Crossing the Quality Chasm, and explores how far we have come since its publication... while also anticipating the road ahead.

"A Road Map For Improving The Performance Of Performance Measures"
Authors: Peter J. Pronovost and Richard Lilford

Although use of performance measures has increased as efforts to improve health care quality have also increased, there is much debate over their effectiveness.  The public wants proof of improved performance and researchers want to ensure that measures have validity.  In this article, the authors discuss the "deadlock" present in the field of quality measurement.

Click here to read the piece.
Click here to read about INQRI teams whose work focused on quality measurement.

New Grantee Team's Work Highlighted on Kansas Public Radio

This week, Dr. Nancy Dunton of the University of Kansas was featured on Kansas Public Radio to discuss her INQRI funded study, "Dissemination and Implementation of Evidence-Based Methods to Measure and Improve Pain Outcomes." This project, co-led by Dr. Susan Beck of the University of Utah, will disseminate and implement evidence-based approaches to measure and improve pain care and outcomes in a sample of 100 hospitals across the United States. The program is unique in forging a partnership with the National Database of Nursing Quality Indicators® (NDNQI).

Click here to access the audio interview.

Click here to find out more information about other recent INQRI funded projects.

This recent study is based on the work of Dr. Beck's 2006 INQRI study, "Measuring Nursing Care Quality Related to Pain Management."

The National Quality Forum needs your help!

The National Quality Forum (NQF) is accepting public comments through July 1, 2010 on their Quality Data Set. This set is an ‘information model' that defines concepts used in quality measures and clinical care and is intended to enable automation of electronic health record use.

Click here to read more about the Quality Data Set.
Click here to go to the comment page.
Click here to read more about NQF.

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.

Are Hospital Rankings Popularity Contests or Measures of Quality?

In an article published yesterday, Janice Simmons wonders if hospital rankings are true measures of quality.

Each year since 1990, U.S. News & World Report has ranked more than 5,000 hospitals in a variety of categories.  They present a "Top 50" in each one, with the goal of helping consumers select the hospital that is right for them.  However, a study recently published in the Annals of Internal Medicine claims that the standings do not really reflect objective measures of quality.

Tell us what you think - are rankings true quality measures?

INQRI Team Offers New Tools to Measure Pain Management

Susan Beck and her colleagues at the University of Utah have published the first phase of their INQRI-sponsored work to develop tools to measure the quality of care related to pain management.

Dr. Beck: The purpose of this phase of our research was to establish content validity of the items and to evaluate whether patients understood each item and were able to make a judgment based on the care provided to them by nurses and their interdisciplinary team. We interviewed 39 hospitalized patients with pain at the end of a nursing care shift. The process allowed the team to produce a 44-item version of the tool that could then be tested in the clinical setting.

Copies of the final version of the tools that resulted from this ongoing work are available upon request. The first tool, "Pain Care Quality (PainCQ) Nursing" includes 14 items that measure three factors: Being Treated Right, Comprehensive Nursing Pain Care, and Efficacy of Pain Management. The second tool, "PainCQ-Interdisciplinary" contains six items that measure Partnership with the Healthcare Team and Comprehensive Interdisciplinary Pain Care. Please contact me at susan.beck@nurs.utah.edu to obtain a copy and request permission to use the PainCQ tools.

You can read the article in the March/April issue of Nursing Research, now available online.

Interested in Weighing in on a New NQF Committee?

The National Quality Forum is seeking to identify and endorse additional measures of outpatient care addressing emergency department and/or urgent care for public reporting and quality improvement. The Additional Outpatient Measures 2010 14-day review of the proposed roster for submitted nominees is now open through Monday, March 22, at 6:00 pm ET. Members and the public can provide comments on the proposed roster and potential vacancies in expertise.

INQRI is very interested in the work of the National Quality Forum (NQF).  Our first call for proposals (CFP) focused on measurement, with a specific interest in testing the effects of implementing the nursing sensitive performance measures endorsed by NQF. Click here to learn about the nine teams funded via our first CFP.

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.

Nursing Care Quality in Acute Care Hospitals: New Linkages to Patient Outcomes

Dr. Arlyss Anderson Rothman and Dr. R. Adams Dudley present their INQRI project: "Nursing Care Quality in Acute Care Hospitals: New Linkages to Patient Outcomes" at the 4th Annual INQRI meeting.





Project Description: Increased public reporting of hospital performance and the emergence of hospital pay-for-performance initiatives provide new impetus to defining and maximizing all aspects of hospital care. This interdisciplinary team has examined whether increases in nurse staffing and skill mix improve hospital performance on a subset of JCAHO core measures, enhance patient perceptions of nursing performance, and improve overall nursing performance as measured by composite indicators that capture patients' perceptions of care and other selected outcomes of care such as complication rates.

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.