As I work with clients looking to improve a clinical or organizational process, I wonder how I can help them operationalize the wisdom of Dr. Berwicks quote. It is time to garner the will and the resources to support direct care nurses as they struggle to document all aspects of their care, to include patient responses. Health Affairs, 30(2), 211-218. (2014). The selection of quality measures sets is guided by conceptual models of quality, scientific standards, and the pragmatics of data collection. A. )J���p����:� _���:� Medical Care Research and Review, 64(2), 144S-169S. 195 0 obj <>stream The development of robust nurse process measures is hindered by issues related to incomplete and unstandardized documentation, documentation burden, and data collection burden. Table 1. outcome. Goals and expected outcomes must be measurable and client-centered. There are no intrinsic benefits in measuring nursing outcomes; rather, the benefits are contingent upon whether or not the act of measurement results in changes that lead to improved quality of care (Farquhar, Kurtzman, & Thomas, 2010). Griffiths, P. (1995). Citation: Jones, T., (May 31, 2016) "Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges" OJIN: The Online Journal of Issues in Nursing Vol. (2013). Not surprisingly, some nurses are unwilling to accept responsibility for outcomes over which they lack complete control. This type of research falls under the umbrella of health services and/or nursing administration research which is notoriously underfunded compared to biobehavioral research (Edwardson, 2006; Holubowich & Andos, 2008; Murphy, Scott, & Warshawsky, 2014). The identified outcomes were hospital-centric and did not reflect the full scope of outcomes included in the profession of nursing’s social mandate or the full range of outcomes assumed to result from good nursing care. Fasolino, T., & Verdin, T. (2015). A., & Tarule, J. M. (2013). For example, evidence from multiple studies of unfinished nursing care indicate that direct care nurses prioritize care based more on what gets measured/audited than on individualized patient needs (Jones, Hamilton, & Murry, 2015). (2011). Bodrock, J. Kurtzman, E. T., Dawson, E. M., & Johnson, J. E. (2008). Therefore, nurses are accountable for and obligated to measure interventions and outcomes in the areas of health promotion, prevention of illness and injury, and alleviation of suffering. Patients typically receive care from teams of semiautonomous providers representing multiple disciplines and specialties working interdependently. endstream endobj 142 0 obj <>/Metadata 13 0 R/Pages 139 0 R/StructTreeRoot 23 0 R/Type/Catalog>> endobj 143 0 obj <>/MediaBox[0 0 612 792]/Parent 139 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 144 0 obj <>stream Timmers, T. K., Hulstaert, P. F., Leenen, L. P., & Luke, P. H. (2014). Washington, DC: National Quality Forum. Outcomes of care are generally regarded as the most important element of quality assessment because they focus on patients and reflect the social mandate and ultimate goals of healthcare providers (i.e., changes in health status) (Donabedian, 2003). ; Measurable: By December, I will only have organic foods and healthy snacks in my pantry. This assumption is foundational to the discipline of nursing and the social contract between nurses and the public. In contrast to frameworks based on the medical model of care (Donabedian, 2003), patient outcome categories proposed in nursing quality frameworks are typically more closely aligned with nursing’s social mandate. Assessing the impact of an electronic medical record on nurse documentation time. State of the science reviews indicate that the challenges of effective quality and outcomes measurement in nursing have changed very little in the past 40 plus years (Alexander, 2007; Griffiths, 1995; Naylor, 2007; Needleman et al., 2007). The article concludes with recommendations for action to move quality assessment forward, such as substantial investment to support adequate documentation of nursing practice and patient outcomes. Similar to outcomes included in the VBP initiative (Table 1) and the first nurse report card (Table 2), the nurse-sensitive patient outcomes endorsed by the NQF (Table 4) exclusively reflect the nurse role in the prevention of a limited number of adverse events. Researchers must be willing to pursue methods beyond secondary analysis of these databases. New York, NY: Oxford University Press. While these tools may result in more complete documentation, they also may increase documentation burden (Cutugno et al., 2015). Fry proposed to nurses that: \"the first major task in our creative approach to nursing is to formulate a nursing diagnosis and design a plan which is individual and which evolves as a result of a synthesis of needs\" (p. 302). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.html, Munyisia, E. N., Yu, P., & Haily, D. (2011). Consequently, the contribution of nursing care to patient outcomes is still not evaluated in many practice settings. Nurse administrators also should consider allocation of additional human resources to address the documentation burden. 1, “competence” falls midway between The only nurse process measure endorsed by the NQF relates to smoking cessation counseling for selected hospitalized patient populations. One overall goal is determined for each nursing diagnosis. Conceptual models for population-focused public health nursing interventions and outcomes: The state of the art. 0 Montalvo, I. Measuring the effectiveness of school nursing interventions: A review of outcome tools. The act of measurement makes phenomena visible and functions to elevate actual and/or potential quality problems in the consciousness of stakeholders. health promoting behaviors, self-care) and alleviation of suffering (e.g. In contrast to disciplines with highly technical interventions (e.g. Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff? Notably, no nurse process measures were selected for further development and none were included in the first report card. Nursing outcomes. More emphasis is needed on establishing clinically meaningful relationships between specific nurse process measures and patient outcomes that reflect the full spectrum included in the nursing profession’s social mandate. However, the act of measurement also consumes human and material resources. Treading water: The no growth investment in health services research. Evidence suggests that direct care nurses are skeptical about whether or not expanded VBP policies will ultimately improve quality and safety for patients, but they are confident that an expansion of quality targets will increase their documentation burden (Kurtzman et al., 2011). They express a benefit or \"value added\" that a student can demonstrate upon completion of an academic program or course. S.M.A.R.T. Introduction of EHRs has indeed changed nursing documentation processes and retrieval of information for analyses. The discipline has long been criticized as a practice based more on tradition than evidence and this criticism has been met with multiple professional initiatives to stimulate evidence based practice and outcomes research. Jones, T. (2011). The changing reimbursement landscape: Nurses’ roles in quality and operational excellence. Notably, nurse-sensitive indicators account for < 3% of the 500-plus measures endorsed by the NQF. The nurse structures were selected based on data availability and the outcomes were selected based on the strength of their theoretical link to nursing care quality. (2007). Moreover, measure specifications and data collection procedures are not standardized (Alexander, 2007; Doran, 2011). New strategies to address the challenges of effective quality assessment and outcome measurement in nursing must be implemented. Alexander, G. R. (2007). Therefore, quality assessment is best achieved through a set of measures that include outcomes and associated structures and processes. Impact of electronic health records on nurses’ productivity. Systematic review and meta-analysis. Learning outcomes describe the learning that will take place across the curriculum through concise statements, made in specific and measurable terms, of what students will know and/or be able to do as the result of having successfully completed a course. The NOC outcomes are grouped in a coded taxonomy that organizes the outcomes within a conceptual framework to facilitate nurses identifying an outcome for use with a patient, family or community. Dr. Jones completed her PhD in 2004 at The University of Texas at Austin and was selected to participate in the NIH-Sponsored Clinical Scholars Program at The University of Texas Southwestern Medical Center at Dallas from 2007-2010. A retrospective exploration of patient-ventilator monitoring intensity, therapeutic intervention intensity, and compliance with lung protective guidelines in a cohort of patients with adult respiratory distress syndrome. Therefore, every additional data field potentially adds to the documentation burden for nurses. Measurable. Forward, C. (2013). To be useful, a measure must provide information that is actionable. Clear objectives help measure your outcomes. Dr. Jones teaches undergraduate and graduate courses focusing on various aspects of leadership, management, evidence-based practice, and quality and safety. Journal of Obstetrics and Gynecology Nursing, 43, 132-133. doi:10.1111/1552-6909.12276. Retrieved from www.va.gov/nursing/docs/office officeofnursingservices-ons_annual_report_2009-web.pdf. It is imperative that nurse administrators proactively drive the design of performance monitoring systems that address the needs of the discipline of nursing. Journal of Advanced Nursing, 21, 1092-1100. Undertake a realistic assessment. Policy, Politics, & Nursing Practice, 9(3), 181-191. Pt will experience decreased incidence of confusion by end of shift on 11/12/08. Halloran, E. J., & Halloran, D. C. (2015). One alternative strategy used by physicians to address documentation burden is to hire scribes to shadow clinicians and document clinical activities and observations (Hertz, 2014). ��k��HK���7 H�c����@�q� Here’s an example: Therefore, documentation screens are often built around endorsed quality measures, particularly those associated with VBP. Their existence, challenges, and importance. However, technological advances and healthcare reform legislation provide new opportunities to address some of these challenges. ). Continued support is unlikely for care providers and processes that lack evidence of a meaningful contribution to these aims. Online Journal of Issues in Nursing, 16(2), 12. doi:10.3912/OJIN.Vol16No02InfoCol01. Following is a summary and critique of the pivotal outcome measurement activities in nursing from the 1970s to the present. 4. (2003). Nursing History Review, 19, 127-155. doi:10.1891/1062-8061.19.127. The social imperative is described in the American Nurses Association (ANA) Social Policy Statement (ANA, 2010) and is codified in each nurse practice act. Kurtzman, E. T., & Jennings, B. M. (2008). Despite decades of intentional efforts to this end, the nurse contribution to patient outcomes has not been sufficiently quantified. For example, a measurable goal for walking: "Mr. Jones will walk ten feet to the bathroom with a rolling walker with minimal assistance in two weeks." Speech recognition for nursing documentation. 2. Consequently, investment of resources in health promotion and alleviation of suffering is more likely to occur if related outcomes are measured and included in VBP policies. Student will be able to articulate the necessity of maintaining office hours as publicized. A consensus report. The NQF standard of feasibility reflects the balance between the cost/burden of data collection and the potential benefit of the information generated. Outcomes are more specific, narrow and measurable. Jones, D. S., & Kessler, H. B. Annals of Internal Medicine, 163, 554-556. doi:10.7326/M15-1933, Patrician, P. A., Loan, L., McCarthy, M., Brosch, L.R., & Davey, K. S. (2010). Relationships among nurse staffing, adherence to practice guidelines, and patient outcomes in the treatment of hypoglycemia. Measurable: The outcomes, indicating the time you achieve the target, are measurable. The purposes of this article are to examine the imperatives, ideals, history, and challenges related to effective outcome measurement in nursing and to identify recommendations for action. Execution of a NMDS requires a standardized language to effectively capture nursing services and outcomes of interest (Mac Neela, Scott, Treacy, & Hyde, 2006). However, empirical evidence to support the unique contribution of nurses to quality outcomes is currently lacking (Needleman, Kurtzman, & Kizer, 2007). Fratzke, J., Tucker, S., Shedenhelm, H., Arnold, J., Belda, T., & Petera, M. (2014). Patient will decrease their depression by 50%.Measurable, time-limited goals Patient will score 20 or below on the Beck Depression Inventoryfor 5 consecutive sessions. Keyboard entry of data into the EHR continues to be as burdensome as handwritten documentation. Computers in Nursing, 33(11), 487-494. doi:10.1097/CIN.0000000000000187. The Donabedian model is a useful organizing framework for quality assessment in healthcare, providing a generic overview of the essential categories of quality measures and supporting the necessity of empirically supported relationships within measure sets. Daly, J., Maas, M. L., & Johnson, M. (1997). Journal of Nursing Care Quality, 12(4), 9-13. Kurtzman, E. T., O’Leary, D., Sheingold, B. H., Devers, K. J., Dwason, E. M., & Johnson, J. E. (2011). Electronic documentation systems have not reduced the documentation burden for nurses. Development and evaluation of nursing user interface screens using multiple methods. Not surprisingly, some nurses are unwilling to accept responsibility for outcomes over which they lack complete control. Consequently, few evidence based changes in practice have materialized. Table 4. If the pt. Once documented, information about nursing processes and patient responses must be retrieved and organized for analysis. American Health & Drug Benefits, 1(6), 34-42. Nursing minimum data sets: A conceptual analysis and review. VanFosson, C. A., Jones, T. L., & Yoder, L. H. (2015). Journal of Health and Human Services Administration, 23(4), 416-442. Quality assessment initiatives are hindered by the paucity of available data related to nursing processes and patient outcomes across these three domains of practice. Medical Economics, 91(7), 44-47. Many believed that this technology would result in significant cost savings through efficiencies gained in documentation and retrieval of clinical information (Jones & Kessler, 2010). This process measure by no means captures the full scope of nursing practice in any practice setting and is not likely to make a significant contribution to the limited number of patient outcomes endorsed by NQF and included in available nurse databases. Evaluating the quality of medical care. The act of measurement makes phenomena visible and functions to elevate actual and/or potential quality problems in the consciousness of stakeholders. Matney, S. A., Maddox, L. J., & Staggers, N. (2014). Ways to stay focused on your patients, not your EHR. has alzheimers, depending on the stage, absence of confusion may not be an acheivable goal. doi:11.1177/1077558707299260, Outland, B., Newman, M. M., & William, M. J. (2011). ��W;U�sa�Eο�&�v����3��RB�c�C�1ɑ'��P*! %PDF-1.5 %���� However, neither has been widely adopted in the United States. The answer comes in focusing o… Therefore, access to better data also will require significant investments by healthcare organizations in clinical documentation systems and more collaborative partnerships with researchers. Therefore, assumptions about the nursing contribution to care must be replaced with empirical evidence of the nursing profession’s actual contributions to care. Limited Scope and Participation in Nursing Databases. All of these databases were designed for the evaluation of nursing care in acute care hospitals, primarily on medical-surgical units. Towards evidence-based management: Creating an informative database of nursing-sensitive indicators. However, outcomes offer no guidance for quality improvement unless they are related to modifiable antecedents (e.g., structures and processes of care). Holubowich, E. J. Washington, DC: American Nurses Publishing. MEDSURG Nursing, 24(6), 397-401. Nurse leaders and scholars have long recognized the need to measure the outcomes of nursing care and have attempted to address the associated challenges at various times throughout history. Structure-Process-Outcome (SPO) Framework for Quality Assessment in Nursing, Donabedian definitions in Figure extrapolated from Donabedian (2003) Using the SMART Process {Measurable.Be clear in the objective about what will be changed and by how much. Quality assessment and outcomes research initiatives have historically been hindered by lack of available data related to nursing processes and patient outcomes across these domains of practice. Each discipline is necessary for recovery of function, yet none is sufficient. However, the very nature of nursing and health outcomes pose significant challenges in the application of these criteria for quality assessment in nursing. Few would engage in the demanding work of nursing without some degree of belief that their efforts make a difference. Here are a few examples to show you the difference between a professional idea and a nursing SMART goal. American Journal of Maternal Child Nursing, 38(5), 320. doi:10.1097/NMC.0b013e31829c0ae0. Nurses are obligated to serve the public good through stewardship of health resources. Few would engage in the demanding work of nursing without some degree of belief that their efforts make a difference. External forces are now facilitating this shift toward an outcome-based practice for nursing and strengthening the imperative for outcome measurement. At the very least, nurse administrators must request and support ongoing testing of user interface screens to maximize efficiency (Hyun, Johnson, Stetson, & Bakken, 2009). The intervention of surveillance also may require communication with other providers to initiate action that falls outside a nurse’s independent scope of practice. Nurse-Sensitive Indicators Originally Identified by ANA, Assessment and Implementation of Patient Care Requirements, Ratio of RNs to Total Nursing Staff (Skill Mix of RNs, LPNs, & Unlicensed Workers), Total Nursing Care Hours Provided Per Patient (Case Mix, Acuity Adjusted), Table 2 extrapolated from Lewin-VHI (1995). ...the active ingredients of nursing care must be identified and quantified. National Quality Forum Endorsed Nurse-Sensitive Indicators. The Department of Health and Human Services (DHHS) supported the development of minimum data sets (MDS) to facilitate these evaluations (Hobbs, 2011). Nursing care is often more difficult to conceptualize and measure than care from other disciplines. The outcomes addressed in current VBP policies primarily relate to the prevention of injury (e.g., nosocomial infection, pressure ulcers) and do not address other outcomes germane to the nursing profession’s social contract (i.e., health promotion and the alleviation of suffering). This action translates into a downsized nursing workforce, fewer patient services, and decreased quality of care (Kurtzman et al., 2011; Timmers, Hulstaert, & Leenan, 2014). this document is to assist applicants to write Specific, Measurable, Achievable, Realistic and Timely (SMART), short-term stoutcome objectives for the 2012/2013, 21 CCLC application. This ANA initiative set the course for the next two decades of activities related to quality and outcomes assessment in nursing. Therefore, a comprehensive evidence-based report card to evaluate the quality of nursing care was not achieved. Compared to abstraction of data from paper based documentation systems, retrieval of data from an EHR for quality analysis and reporting is more efficient (Alexander, 2007). Thus, there is insufficient evidence to explain how nurses contribute to outcomes. Terry L. Jones, PhD, RN When performance on an outcome influences provider reimbursement, the increased attention is often accompanied by a reallocation of resources to correct the problem. Refinement of the user interface alone will not likely be sufficient. }ҋ;��n��Y�=��3uG�cJ7r��_��&7qRl���/�d\K��v���`�’9��nYuo��O���+?L�J�4�q|6x�+�P�2p�{����>��3~�Ox+��>6zQ?y�߅��a$�>���fU�JٺS1�%��%\̠J���c�zS��.tn=��Y���LK��5�� The limited range of endorsed patient outcomes is problematic. The National Database of Nursing Quality Indicators (NDNQI), Online Journal of Issues in Nursing, 12(3). Nursing Outlook, 64(2), 124-136. doi:10.1016/joutlook.2015.12010, Veteran’s Health Affairs. Nursing minimum data sets. Measures based on data collection methodologies intrinsic to care processes and captured by existing data systems are highly desirable (Burston, Chaboyer, & Gillespie, 2013; Needleman et al., 2007). Consequently, a core group of nurse leaders collaborated to develop an MDS specific to nursing (NMDS). Your goals are a great start but you just need to add to them: 1. surgical procedures), many nursing interventions are more akin to the information transfer process of knowledge workers, and therefore more difficult to isolate and measure (Matney, Maddox, & Staggers, 2014). Email: Tjones0222@aol.com. Nursing outcomes classification. The usability standard reflects the degree to which a measure is understandable to those making decisions that influence quality. Nursing–Sensitive Indicators included in Major Nursing Databases, Catheter Associated Urinary Tract Infection, Central Line Associated Blood Stream Infection, Patient Satisfaction with Discharge Planning, Patient Satisfaction with Pain Management, a=National Database of Nursing Quality Indicators (Montalvo, 2007) Farquhar, M., Kurtzman, E. T., & Thomas, K. A. Journal of Nursing Scholarship, 36(4), 371-378. Instead of continuing to search for relevance in available data, efforts must shift to making the collection of relevant data more feasible. Heslop, L. & Lu, S. (2014). Short Term and Long Term Goals. Hakes, B., & Whittington, J. Address the full continuum of outcomes expected to be influenced by the intervention of interest. His now-famous quote about making quality improvement measureable says, Some is not a number; soon is not a time. An essential element in data sets for nursing and health care effectiveness. Writing outcome statements "Outcomes - are specific, measurable statements that let you know when you have reached your goals. Electronic prompts and forcing functions can be added to reduce lapses in documentation. The combined dependent, independent, and interdependent components of nursing practice add to this challenge (Doran, 2011). Hobbs, J. Therefore, health outcomes are rarely, if ever, the result of a singular process or provider. The following examples are taken from the Doctor of Veterinary Medicine program from Texas A&M. The evaluation process included a review of empirical evidence to support presumed linkages and an assessment of data quality and availability. Teaching and Learning in Nursing, 8, 120-127. doi:10.1016/j.teln.2013.05.001. Naylor, M. D. (2007). While adverse events are important, the question remains as to whether or not they should receive a disproportionate share of nursing attention and organizational resources compared to other quality problems. Objectives are used to organize specific topics or individual learning activities to achieve the overall learning outcome. (2011). Performance measurement of nursing care. Meaningful use and its impact on healthcare technology management. For example, achievement of high functional status in a patient diagnosed with a cerebrovascular accident requires diagnostic and therapeutic interventions from physicians, nurses, physical therapists, occupational therapists, and dieticians. Nursing and threats to patient and nurse safety and quality of patient care. Western Journal of Nursing Research, 36(2), 171-190. doi:10.1177/0193945913497111, McCartney, P. R. (2013). The evidence base linking nurse structures with patient outcomes related to adverse events is much more robust than at the time of the ANA report card initiative (Brennan, Daly, & Jones, 2013; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Krueger, Funk, Green, & Kuznar, 2013; Lankshear, Sheldon, & Maynard, 2005). Recent evidence also suggests that bedside nurses are still reluctant to adopt a standardized nursing taxonomy (Halloran & Halloran, 2015; Schwiran & Thede, 2011). Thus, quantifying the unique contributions of each individual discipline is challenging. Quraishi, J., & Jordan, L. (2014). Nursing Economic$, 33(4), 219-226. The current state of nursing performance measurement, public reporting, and value-based purchasing. She has been a nurse for over 30 years and has served in a variety of roles ranging from critical care staff nurse to Chief Nurse Executive in a large academic medical center. Performance-based payment incentives increase burden and blame for hospital nurses. Set short term goals with a time frame for each skill area. Examining the nursing contribution to quality patient outcomes continues to be the primary focus of her program of research. Nurses as knowledge workers: Is there evidence of knowledge in patient handoffs? 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