Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy

By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of INQRI. This commentary originally appeared on the Institute of Medicine website.

The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.

This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.

More than 3.1 million strong, nurses represent the largest segment of the health care professional workforce in the United States and are the professionals who provide the most direct patient care. But, until the launch of the INQRI program, there was little rigorous research linking nursing’s contributions to patient outcomes. INQRI has served to advance the science of health care by investigating those linkages and providing evidence to inform policies and practices that improve patient care and outcomes, thereby improving our health care system overall.

Since INQRI’s launch, the program has encouraged researchers to develop new strategies to improve health care value and demonstrate nursing’s role in accomplishing that aim. To date, INQRI has supported 48 multidisciplinary teams of scholars whose studies have dramatically increased the evidence linking nursing to quality of care. These teams not only examine the nursing practices and processes that affect the patients’ experience with care and outcome, but also design and implement nurse-led interventions to improve patient outcomes. Equally important, findings from INQRI teams have helped to distinguish effective ideas from solutions that are often popular, yet ineffective.

A series of articles recently published in a special supplement of Medical Care revealed that, collectively, these studies have helped to improve the rigor of research methodology, built a solid base of evidence demonstrating linkages between nursing care and patient outcomes, and helped advance interdisciplinary research and practice. To a large extent, INQRI’s contributions to our knowledge are a function of the singular requirement that every INQRI research team include investigators from more than one discipline. As IOM’s Roundtable on Value & Science-Driven Health Care has drawn on the insights of a multidisciplinary community, so have INQRI teams. By requiring that researchers collaborate across disciplines, the program raises the bar for the level of rigor, ensuring that diverse perspectives contribute to the design of each study and are also brought to bear in the analysis of the findings.

The roundtable has sought to accelerate progress through six stakeholder Innovation Collaboratives: 1) Best Practices; 2) Clinical-Effectiveness Research; 3) Evidence Communication; 4) Digital Learning; 5) Systems Approaches for Health; and 6) Value Incentives. To make significant change, we must look at all aspects of the health care system. To that end, INQRI attempts to understand the nurses’ role in delivering high-quality care across a variety of patient populations and settings.

INQRI has funded several studies that examined nursing practices and tested interventions that can improve patient care and safety, including

• changes in nursing processes and the practice environment to facilitate nurses’ ability to intercept costly and dangerous medication errors;
• nurse-led innovations to reduce the incidence of facility-acquired
• pressure ulcers among residents in long-term care settings; and
• strategies to improve intensive care unit patients’ ability to communicate with nurses and other health team members regarding their care needs and preferences.

INQRI grantees have also applied rigorous research methods to examine a broad range of approaches to improving the value of health care—increasing quality while reducing health care costs associated with issues such as patient falls, hospital-acquired infections, and rehospitalizations. Studies aimed at reducing events that drive up health care costs have included

• an analysis of the factors that influence the quality of preparation of patients and family caregivers for the transition from hospitals to home and the impact of enhanced preparation on patients’ perceived readiness and rates of re-hospitalization;
• relationships between the level of professional nursing practice, adoption of evidence-based care strategies, and the number and kind of injuries from falls;
• effects on patients’ health of diabetes prevention information delivered by visiting nurses to residents in subsidized housing units; and
• linkages between nurse staffing levels in neonatal intensive care units and outcomes for very-low-birth-weight infants in those units.

In addition to contributing to continuous learning in our nation’s health care system, improving the rigor of research, and identifying the linkages between nursing and the quality of patient care, INQRI has helped to define what we mean by “quality” in the context of health care and to identify new metrics and measures that should be used in future health care research. As any research endeavor should, INQRI has proven to be greater than the sum of its parts.

Suggested citation: Naylor, M. Promoting rigorous interdisciplinary research and building an evidence base to inform health care learning, practice, and policy. Commentary, Institute of Medicine, Washington, DC. http://iom.edu/interdisciplinaryresearch

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.

Health Wonk Review Carnival Now Live

Check out this week's edition of the Health Wonk Review over at the Workers' Comp Insider blog.  Mark Pauly's post from this week is featured in the carnival along with a lot of other great reads.  Take a look. 

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?

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.

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.

The INQRI Challenge

“INQRI will never stop challenging us,” a nurse researcher said.  “First, you told us we had to work across disciplines; then you told us to work across teams.  INQRI made us do everything differently!  I don’t know if you really know how hard that is… but, I’m never going to do it any other way again.”

Although said casually in passing during last year’s Interdisciplinary Nursing Quality Research Initiative (INQRI) national conference, that statement sums up something key about this program.

We have never been interested in business as usual.

The Robert Wood Johnson Foundation launched the INQRI program in 2005 to generate, disseminate, and translate research to understand how nurses contribute to and can improve the quality of patient care. As the INQRI leadership team, we strongly supported this goal, but we knew that we needed to adopt a new approach to nursing research.  In our initial strategy sessions, we realized that INQRI would demand that its grantees think outside the box and collaborate in new ways.  We required that all our teams be co-led by a scholar from nursing and one from outside of nursing.  We knew that an interdisciplinary focus would be challenging to researchers who were accustomed to staying within their comfort zones, but that the potential risks would be worth the rewards.

Lori Melichar, Mark Pauly, Mary Naylor, Heather Kelley

Over the course of the program, INQRI has funded 40 interdisciplinary teams to produce evidence that better nursing improves quality of care by reducing medical errors and identifying measures, processes and protocols that help health systems and health professionals ensure the best patient outcomes possible. We have heard time and again from these teams that without the “push” from us to work in collaboration with new partners, it is unlikely that researchers would have reached out to scholars from other disciplines.  Some of the nurse investigators told us that without INQRI asking, “well, why not?” they never would have submitted papers about nursing for publication in the Journal of the American Medical Association or Health Services Research.  Perhaps most gratifying, we’ve heard team members say time and time again that INQRI has convinced them to always pursue future projects with an interdisciplinary team in place.

We are proud of our teams’ efforts and we continue to support the promotion of their work, but we also knew that at our national conference in April 2012, we again would not be pursuing business as usual.  We were not interested in an event where individual team members reported their findings.  Instead, we issued a new challenge.  A select group of INQRI grantees were asked to use 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.  We encouraged these scholars to write papers which, in addition to summarizing previous results and presenting new ones, provided additional insights into the implications of their results for health policy, for the fields of quality measurement and quality improvement, and for translation sciences. In keeping with the collaborative nature of the INQRI program, the selected grantees developed the papers in partnership with other INQRI research teams across a mix of disciplines.  These papers were developed for inclusion in a special supplement of Medical Care and were presented for feedback during the conference.

Last April, we were joined not only by INQRI grantees from all years of the program, but also by RWJF leaders, our National Advisory Committee members, stakeholders from a range of disciplines, students new to the field, and more.  We were thrilled to hear about the wonderful experiences our grantees had over the course of the program and truly gratified to learn from our invited guests that they had developed a strong appreciation for the work of our teams.  There was a buzz in the air as new collaborations formed, new projects were planned, and memories were shared.

Now, we want to continue that feeling of excitement with the publication of that long-planned special supplement.  This week, we are hosting a blog carnival which will provide more information about the supplement as well as the program itself.  Watch this space for exciting updates, videos, and more.  In the meantime, be sure to visit www.inqri.org and the Medical Care site to access the supplement.

As we pause this week to acknowledge the tremendous accomplishments of our grantee teams, we also recognize the need for continued exploration of the field.  We wanted to demonstrate that there is a causal link between nursing and quality and we feel confident that INQRI research has done that.  But, we also recognize that there is work ahead.  Future endeavors must focus on efforts that have fiscal feasibility, which can be sustained over time.  We must not neglect the business case for quality to truly have an impact on the delivery of care.  So, please join us in celebrating this week… and in thinking about how to accomplish all that lies ahead.  Onward!

Mary Naylor, Program Director

Mark Pauly, Program Co-Director

Lori Melichar, Senior Program Officer

Heather Kelley, Program Associate

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 Director to be Honored at FNINR Gala

Congratulations to INQRI's program director, Mary D. Naylor, PhD, RN, FAAN, who will be honored this evening at the Friends of the National Institute of Nursing Research (FNINR) Gala when she is presented with the FNINR President’s Award.  This award is presented for having achieved a sustained program of research in the area of health intervention research.

Dr. Naylor is the Marian S. Ware Professor in Gerontology at the University of Pennsylvania, School of Nursing. Since 1990, Dr. Naylor has led an interdisciplinary program of research designed to improve the quality of care, decrease unnecessary hospitalizations and reduce health care costs for vulnerable community-based elders. To date, Dr. Naylor and her research team have completed three National Institutes of Health funded randomized clinical trials testing the Advanced Practice Nurse Transitional Care Model, an innovative approach to addressing the needs of high risk chronically-ill elders and their caregivers. With the support of The Commonwealth Fund, the Jacob & Valeria Langeloth Foundation and the John A. Hartford Foundation, this research team has recently partnered with a major insurance organization and health care organization to promote widespread adoption of this proven model of care coordination. An ongoing clinical trial funded by the Marian S. Ware Alzheimer Program and the National Institute on Aging has expanded testing of this model of care with hospitalized cognitively impaired elders and their caregivers. Additionally, Dr. Naylor and colleagues have just launched a study funded by the National Institute on Aging and the National Institute for Nursing Research that will examine over time the natural history of changes in health and quality of life among elders newly admitted to long term care settings or services. In recognition of her research and leadership, Dr. Naylor has received numerous awards. In 2005, Dr. Naylor was elected to the National Academy of Sciences, Institute of Medicine. She also is a member of the RAND Health Board, the National Quality Forum Board of Directors and the immediate past-chair of the Board of the Long-Term Quality Alliance. She was appointed to the Medicare Payment Advisory Commission in 2010.

For information about the FNINR and the other awards that will be presented this evening, please visit their website.

Please click here for more information about Dr. Naylor's program of research.

Free Webinar Highlighting Healthcare Transitions and Coordination

Next week, former INQRI grantee, Gerri Lamb, PhD, FAAN, RN, is the featured guest for a webinar focusing on how healthcare transitions and coordination affect early readmissions, care effectiveness and the economics associated with the two. This is the second webinar in this two part series that highlights the importance of care transitions.

To register for the upcoming webinar, click here.

To view the first webinar of the two part series, which featured INQRI director, Mary D. Naylor, PhD, RN, click here.

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.

Reflections on INQRI's Work - A Video Presented At Last Week's 2012 National Conference

As many of you know, or may have attended, the INQRI Program held our National Conference last week in Washington, DC. We had the pleasure of engaging the 160+ participants with panels discussing the many facets of INQRI grantees' work. One of the most talked about sessions of the conference was the introductory section, which included a video reflecting on the work of INQRI since its inception 7 years ago. The video is embedded below.



If you are looking for more resources related to the INQRI program's work you can visit our BRAND NEW website that contains a variety of videos, documents, as well as general information about the INQRI program and the grantees we have served over the years.

Interdisciplinary Nursing Quality Research Initiative (INQRI) National Conference Starts Today`

We are eager with anticipation for the start of our National Conference, which begins at 2pm EST today. For those of you who are unable to attend, you can view the agenda for this event here.

We will be live tweeting as much of the event as possible and highlighting the wonderful keynote speech that Dr. Ezekiel Emanuel has prepared for our conference tomorrow.

Make sure to follow our twitter feed @INQRIProgram for live updates from the meeting and feel free to get in touch with the program if you are interested in receiving a media packet after our conference has concluded.

We look forward to welcoming all of you that will be joining us and sharing the experience via Twitter and our blog for those of you unable to join us.

INQRI Program Co-Director Interviewed for Last Month's Women's History Month

Yesterday, Stephanie Bouchard, Associate Editor for healthcarefinancenews.com, published her interview with INQRI's Co-Director Dr. Mary Naylor that discussed the role of women in healthcare. The interview provides great insight of Dr. Naylor's views on women leaders, decision makers and their continued role in improving the United States' health care system.

Click here to read the full interview.

INQRI Program Co-Director Awarded The William B. Graham Prize

We are pleased to share with all of you that Mark Pauly, Ph.D., INQRI's Co-Director, has been named the 2012 winner of the William B. Graham Prize for Health Services Research. Dr. Pauly follows a long line of distinguished recipients of this award including former CMS Administrator Dr. Donald Berwick; AHRQ Director, Carolyn Clancy; and INQRI NAC member, Dr. Linda Aiken. The award program is funded by the Baxter International Foundation, administered by the Association of University Programs in Health Administration (AUPHA) and is considered to be one of the most prestigious and highly regarded recognitions a health services researcher can receive.

Please join all of us at the INQRI Program in congratulating Dr. Pauly on such a wonderful achievement.

To learn more about the William B. Graham Prize, click here.