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.

Scores Predict Readmission Likelihood

Through a simple risk score, a team from Brigham and Women's Hospital in Boston, collaborating with a team in Bern, Switzerland, say they can identify roughly one-fourth of a hospital's patient population with the highest likelihood of being readmitted, and then within that group the 18% whose readmissions were potentially avoidable, for whom more expensive, intensive efforts might be worth the money.  Continue reading the article.

Readmissions is an area of interest to INQRI.  Grantees Dr. Marianne Weiss and Dr. Olga Yakusheva have conducted research on the discharge process and it's relationship to readmissions.  Learn more about their work:

View "Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization."
View "Age-related differences in perception of quality of discharge teaching and readiness for hospital discharge."
View "Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization."

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.

Ohio Medicaid Program Incentivizes High Quality Care For Nursing Homes

Starting last month, Ohio' Medicaid program altered its payment procedures to reflect the current trend of moving slowly away from a fee-for-service scheme to adapt to pay-for-performance reimbursement schemes. Ohio's new payment policy links approximately 10% of all Medicaid reimbursements for nursing homes to a wide range of quality measures including, patient satisfaction, rate of errors and nurse staffing levels.

To read more about this initiative, head over to Kaiser Health News for a more thorough explanation of this, and similar programs.

Newly Released Videos From The INQRI 2012 National Conference

We are pleased to share with all of you three few videos from the INQRI National Conference that took place on April 24-25th of this year. Continue to keep an eye on our blog as we will continue to upload new material from this wonderful and highly successful conference.

“INQRI Leadership Team”

In these clips from the 2012 INQRI national conference, leadership team members Lori Melichar (senior program officer), Mary Naylor (program director), and Mark Pauly (program co-director) share their reflections about INQRI's beginnings, its impact and the stage it has set for the future.





“INQRI Panel: Trends in Interdisciplinary Collaboration”
Presented by INQRI grantees: Cindy Corbett, Linda Costa and Michele Balas
Moderated by David Krol from the Robert Wood Johnson Foundation.

A select group of INQRI grantees used their findings as the basis for discussions about the relationship between their research and trends in interdisciplinary collaboration, methodology and implementation science, quality measurement, dissemination and implementation, and the business case for nursing.

INQRI Panel: Measuring Nurses' Contribution to the Quality of Health Care

Presented by INQRI grantees: Susan Beck, Marianne Weiss, Nancy Ryan-Wenger, Nancy Donaldson.
Moderated by INQRI NAC Member Shelley White-Means.

At INQRI's national conference (April 26-27, 2012), a select group of INQRI grantees used their findings as the basis for discussions about the relationship between their research and trends in interdisciplinary collaboration, methodology and implementation science, quality measurement, dissemination and implementation, and the business case for nursing.

Nursing Excellence Improves Outcome for High-Risk Infants‎

We are pleased to share with you a recently published study in JAMA conducted by INQRI cohort 2 grantees Dr. Eileen Lake, Dr. Jeannette Rogowski and colleagues, which found hospitals designated by the American Nurses Credentialing Center as a "RNE" hospital provide high quality care in three quality measurement areas. These hospitals, who have obtained the "RNE" designation by achieving exemplary practice or leadership in five areas, had significantly better outcomes than hospitals without this designation in rates of hospital infection, severe intraventricular hemorrhage, and death after seven day. Surprisingly, this study found no significant difference in the death rate of low birth weight infants after 28 days of birth between those hospitals with "RNE" designation and those that did not receive this credential.

Click here to read more about this study.

Click here to read the actual study (subscription required).