Transcript how do nurses influence quality?

HOW WE ALL BENEFIT
WHEN FRONT LINE NURSES
UNDERSTAND QUALITY
SHOSHANNA SOFAER, DR.P.H.
SCHOOL OF PUBLIC AFFAIRS
BARUCH COLLEGE
CITY UNIVERSITY OF NEW YORK
OVERVIEW
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 Who influences quality?
 How do nurses influence quality?
 What does the public think about how nurses
influence quality?
 Why we measure quality
 How can we measure how nurses contribute to
quality?
 What can you do about quality?
American Nurses Association
November 20, 2012
WHO INFLUENCES QUALITY?
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 Health care is complex
 Many people, including clinicians, patients, family
members and managers can influence quality
 Among clinicians, most members of the public seem
to think that it is the individual physician who makes
the most difference
 However, it is clear that everyone on the clinical
team, and those who create the context for their
work, all make a difference
 Indeed, the extent to which the team really IS a team
is very important
American Nurses Association
November 20, 2012
WHO INFLUENCES QUALITY?
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 This is true across settings
 Hospitals
 Ambulatory care
 Home health care
 Nursing homes
 In the community
 And for all kinds of quality problems
 Overuse
 Underuse
 Misuse
 Safety
American Nurses Association
November 20, 2012
HOW DO NURSES INFLUENCE QUALITY?
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 Nurses are everywhere – across settings and playing
multiple roles
 Some focus exclusively on quality, often managing
quality measurement, assurance or improvement
 Some manage those on the front lines and should
take responsibility for supporting high quality care
 Most do not appear to focus on quality, i.e. they do
the actual clinical work, but these are the people who
can and do actually influence quality the most – for
good, or not so good
American Nurses Association
November 20, 2012
HOW DO NURSES INFLUENCE QUALITY?
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 Front-line nurses influence quality by doing the right
thing at the right time in the right way
 This includes:
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Initial assessments
Developing and carrying out their own care plan
Following (or when appropriate questioning) the
overall care plan (i.e. what the doctor ordered)
Monitoring closely patient’s response to care
Supervising and supporting others with less expertise
or experience
Being a productive member or leader of a team
American Nurses Association
November 20, 2012
HOW DO NURSES INFLUENCE QUALITY?
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 The National Quality Forum (NQF) is a non-profit
organization with a mandate to “endorse” measures
of quality if they meet technical and policy-oriented
criteria
 For example, to be endorsed an measure must
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Examine something of significance to individuals and
society
Be valid and reliable
Be usable and, ultimately, be used
American Nurses Association
November 20, 2012
HOW DO NURSES INFLUENCE QUALITY?
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 NQF endorsed 15 “nursing sensitive” hospital quality
measures
 By doing so, they were saying these are specific ways
that we can measure in which nurses influence
hospital quality
 Your handout presents these 15 measures, translated
into plain English rather than using technical jargon
such as “failure to rescue”
 We translated because we wanted to see if the public
found these measures important and useful to them
and could understand what they were getting at
American Nurses Association
November 20, 2012
HOW DO NURSES INFLUENCE QUALITY?
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 What do you think?
 Do you and your colleagues make a difference in
these areas?
 Notice that some of them are pretty important from
a clinical perspective, even “life and death”
 Others are quite different, like the more “structural”
measures of the work environment, staffing ratios
and nursing mix
 And just a few focus on process
American Nurses Association
November 20, 2012
WHAT DOES THE PUBLIC THINK?
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 In the last 20 years, literally thousands of quality
measures have been identified or developed
 More and more of them are being included in reports
to the public to compare the quality of different
health care providers
 Many of the measures in these reports, however,
have never been tested to see if they matter to
consumers and patients
 We wanted to do just that with these nursing
measures
American Nurses Association
November 20, 2012
WHAT DOES THE PUBLIC THINK?
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 We conducted nine focus groups in three cities to
find out what recent hospital patients of all kinds
thought of these measures
 Here’s what we learned:
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Most of the “safety” measures were considered very
important by almost everyone
People, based on their own life experience, thought
that the working environment of nurses would also be
very important
Almost no one cared about the smoking measures
American Nurses Association
November 20, 2012
WHAT DOES THE PUBLIC THINK?
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 Here’s what we learned (continued):
 People were uncertain about the measures of falls
and restraints
 People didn’t really “get” the measures of things like
“nursing mix” or turnover
 Overall, the public isn’t sure what nurses are actually
responsible for – they didn’t want to blame nurses if
nurses were not responsible
 However, this meant they ended up thinking that
physicians were responsible
 Although typically someone pointed out that the
nurses is always there, unlike the physician
American Nurses Association
November 20, 2012
WHAT DOES THE PUBLIC THINK?
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 Here’s what we learned (continued):
 The public trusts and depends on nurses but they
don’t have a true sense of what they DO
They tend to think nurses do only what the physician tells
them to do
 Instead of realizing that nurses have their own care plan
independent of the physician
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The public has high expectations of nurses
They expect them to know what they need even if they
don’t tell them
 They expect them to have the answers to almost all their
questions
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American Nurses Association
November 20, 2012
WHY DO WE MEASURE QUALITY?
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 There are two major reasons we measure quality, outside
of a purely research context
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To increase accountability
To improve care
 We now live in a time when the quality of health care is
not taken for granted; we have to demonstrate that we
provide quality of care, and we DO NOT always do it
 Given that quality can be improved, we have an
obligation, especially given how much money we spend
on health care, to improve it as much as possible
 We can’t improve it, however, if we don’t measure it
American Nurses Association
November 20, 2012
WHY DO WE MEASURE QUALITY?
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 To measure quality, we have to define it
 Whose definition do we use?
 What role do nurses play in defining quality? What
role should they play?
 Right now, nurses are not as involved as they could
be and should be in defining quality
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Does the front line nurse realize that they as a
profession can benefit from participating in quality
measurement? Probably not?
Many see quality measurement as just more time
documenting rather than caring for patients
American Nurses Association
November 20, 2012
WHY DO WE MEASURE QUALITY?
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 Another issue: who is responsible for quality overall?
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For specific aspects of quality? How do nurses fit in?
Nurses do many things on their own
But they do most things with other people; they
collaborate and communicate
So this makes their role “fuzzy” to many
It is hard to see this in the abstract – easier when you
talk about something concrete like avoiding a central line
infection
But even here – lots of people have a piece of the puzzle!
American Nurses Association
November 20, 2012
GETTING INVOLVED IN MEASURING AND
IMPROVING NURSING QUALITY
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 What can front line nurses do about measuring
nursing quality?
 First, think about it
 Ask yourself and your colleagues
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Are we being measured now?
How?
Does that make sense?
What’s important but not getting measured?
What’s the connection between all this paperwork
that I do and measuring quality?
American Nurses Association
November 20, 2012
GETTING INVOLVED IN MEASURING AND
IMPROVING NURSING QUALITY
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 An example: Hospital CAHPS (Consumer
Assessment of Health Providers and Systems)
 A survey of recent hospital patients
 Being used now not only to report on performance to
the public but to determine how much hospitals get
paid
 Many items in this survey involve nurses, e.g.:
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Patient-Nurse communication
Information about medications
Pain management
Staff responsiveness
American Nurses Association
November 20, 2012
GETTING INVOLVED IN MEASURING AND
IMPROVING NURSING QUALITY
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 Do you know what these items are?
 Do you know how your hospital is doing on these items,
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compared to others?
How is your hospital responding?
What do you think can be done to improve scores?
Specifically, what can nurses do?
How can nurses help more generally, by getting involved
in quality improvement efforts
This won’t improve by shaming and blaming
It will only improve if people realize they can do it and
will be better off if they do it
American Nurses Association
November 20, 2012
GETTING INVOLVED IN MEASURING AND
IMPROVING NURSING QUALITY
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 Quality measurement and improvement are not
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going away
The standing of nursing as a profession will depend
in part on what they contribute to health care quality
Nursing can let other health professionals make the
decisions, or they can get in the mix
In many ways, they know more about the specific
moment by moment processes of delivering care
They have a lot to contribute and to gain
American Nurses Association
November 20, 2012